Early Rehabilitation Reduces Time to Decannulation in Patients With Severe Acquired Brain Injury: A Retrospective Study

Development and validation of a nomogram for tracheotomy decannulation in individuals in a persistent vegetative state: A multicentre study

BACKGROUND

Decannulation for people in a persistent vegetative state (PVS) is challenging and relevant predictors of successful decannulation have yet to be identified.

OBJECTIVE

This study aimed to explore the predictors of tracheostomy decannulation outcomes in individuals in PVS and to develop a nomogram.

METHOD

In 2022, 872 people with tracheostomy in PVS were retrospectively enrolled and their data was randomly divided into a training set and a validation set in a 7:3 ratio. Univariate and multivariate regression analyses were performed on the training set to explore the influencing factors for decannulation and nomogram development. Internal validation was performed using 5-fold cross-validation. External validation was performed using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA) on both the training and validation sets.

RESULT

Data from 610 to 262 individuals were used for the training and validation sets, respectively. The multivariate regression analysis found that duration of tracheostomy tube placement≥30 days (Odds Ratio [OR] 0.216, 95 % CI 0.151-0.310), pulmonary infection (OR 0.528, 95 %CI 0.366-0.761), hypoproteinemia (OR 0.669, 95 % CI 0.463-0.967), no passive standing training (OR 0.372, 95 % CI 0.253-0.547), abnormal swallowing reflex (OR 0.276, 95 % CI 0.116-0.656), mechanical ventilation (OR 0.658, 95 % CI 0.461-0.940), intensive care unit (ICU) duration>4 weeks (OR 0.517, 95 % CI 0.332-0.805), duration of endotracheal tube (OR 0.855, 95 % CI 0.803-0.907), older age (OR 0.981, 95 % CI 0.966-0.996) were risk factors for decannulation failure. Conversely, peroral feeding (OR 1.684, 95 % CI 1.178-2.406), passive standing training≥60 min (OR 1.687, 95 % CI 1.072-2.656), private caregiver (OR 1.944, 95 % CI 1.350-2.799) and ICU duration<2 weeks (OR 1.758, 95 % CI 1.173-2.634) were protective factors conducive to successful decannulation. The 5-fold cross-validation revealed a mean area under the curve of 0.744. The ROC curve C-indexes for the training and validation sets were 0.784 and 0.768, respectively, and the model exhibited good stability and accuracy. The DCA revealed a net benefit when the risk threshold was between 0 and 0.4.

CONCLUSION

The nomogram can help adjust the treatment and reduce decannulation failure.

REGISTRATION

Clinical registration is not mandatory for retrospective studies.

A Pluridisciplinary Tracheostomy Weaning Protocol for Brain-Injured Patients, Outside of the Intensive Care Unit and Without Instrumental Assessment: Results of Pilot Study

Concurrently to the recent development of percutaneous tracheostomy techniques in the intensive care unit (ICU), the amount of tracheostomized brain-injured patients has increased. Despites its advantages, tracheostomy may represent an obstacle to their orientation towards conventional hospitalization or rehabilitation services. To date, there is no recommendation for tracheostomy weaning outside of the ICU. We created a pluridisciplinary tracheostomy weaning protocol relying on standardized criteria but adapted to each patient's characteristics and that does not require instrumental assessment. It was tested in a prospective, single-centre, non-randomized cohort study. Inclusion criteria were age > 18 years, hospitalized for an acquired brain injury (ABI), tracheostomized during an ICU stay, and weaned from mechanical ventilation. The exclusion criterion was severe malnutrition. Decannulation failure was defined as recannulation within 96 h after decannulation. Thirty tracheostomized ABI patients from our neurosurgery department were successively and exhaustively included after ICU discharge. Twenty-six patients were decannulated (decannulation rate, 90%). None of them were recannulated (success rate, 100%). Two patients never reached the decannulation stage. Two patients died during the procedure. Mean tracheostomy weaning duration (inclusion to decannulation) was 7.6 (standard deviation [SD]: 4.6) days and mean total tracheostomy time (insertion to decannulation) was 42.5 (SD: 24.8) days. Our results demonstrate that our protocol might be able to determine without instrumental assessment which patient can be successfully decannulated. Therefore, it may be used safely outside ICU or a specialized unit. Moreover, our tracheostomy weaning duration is very short as compared to the current literature.

Behavioral Assessment With the Coma Recovery Scale-Revised Is Safe and Feasible in Critically Ill Patients With Disorders of Consciousness

OBJECTIVES

Accurate classification of disorders of consciousness (DoC) is key in developing rehabilitation plans after brain injury. The Coma Recovery Scale-Revised (CRS-R) is a sensitive measure of consciousness validated in the rehabilitation phase of care. We tested the feasibility, safety, and impact of CRS-R-guided rehabilitation in the ICU for patients with DoC after acute hemorrhagic stroke.

DESIGN

Retrospective cohort study.

SETTING

This single-center study was conducted in the neurocritical care unit at the University of Maryland Medical Center.

PATIENTS

We analyzed records from consecutive patients with subarachnoid hemorrhage (SAH) or intracerebral hemorrhage (ICH), who underwent serial CRS-R assessments during ICU admission from April 1, 2018, to December 31, 2021, where CRS-R less than 8 is vegetative state/unresponsive wakefulness syndrome (VS/UWS); CRS-R greater than or equal to 8 is a minimally conscious state (MCS).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Outcomes included adverse events during CRS-R evaluations and associations between CRS-R and discharge disposition, therapy-based function, and mobility. We examined the utility of CRS-R compared with other therapist clinical assessment tools in predicting discharge disposition. Seventy-six patients (22 SAH, 54 ICH, median age = 59, 50% female) underwent 276 CRS-R sessions without adverse events. Discharge to acute rehabilitation occurred in 4.4% versus 41.9% of patients with a final CRS-R less than 8 and CRS-R greater than or equal to 8, respectively (odds ratio [OR] 13.4; 95% CI, 2.7-66.1; p < 0.001). Patients with MCS on final CRS-R completed more therapy sessions during hospitalization and had improved mobility and functional performance. Compared with other therapy assessment tools, the CRS-R had the best performance in predicting discharge disposition (area under the curve: 0.83; 95% CI, 0.72-0.94; p < 0.0001).

CONCLUSIONS

Early neurorehabilitation guided by CRS-R appears to be feasible and safe in the ICU following hemorrhagic stroke complicated by DoC and may enhance access to inpatient rehabilitation, with the potential for lasting benefit on recovery. Further research is needed to assess generalizability and understand the impact on long-term outcomes.

Body-weight support gait training in neurological intensive care: safety, feasibility, and delays before walking with or without suspension

BACKGROUND

Early Mobilization in Intensive Care Units (ICUs) enhances patients' evolution, but has been rarely studied in neurological ICUs. The aim of this study was to assess gait training with body-weight support (BWS) in neuroICU, and to report on its safety, feasibility and on delays before walking with and without BWS.

METHODS

This study was an observational one-year single-center study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria.

RESULTS

Patients' conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, and 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, and 33 performed BWS walking. Among non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Among the 45 eligible patients who did not receive BWS training, main reasons were workload and weekends (31%), medical barriers (29%), and early ICU discharge (22%). 78 BWS sessions were performed on the 33 beneficiaries (median sessions per patient 2, max 10). Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small, and recovered spontaneously after the session. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), and battery failure (1). None of these adverse events required medical intervention, patients recovered upon session interruption. Median session duration was 31 min, patients walked on median 17 m. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended.

CONCLUSIONS

Verticalization and walking using a suspension device in patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated.

TRIAL REGISTRATION

ClinicalTrials database (ID: NCT04300491).

Early Mobilization for Critically Ill Patients

Advances in the field of critical care medicine have helped improve the survival rate of these ill patients. Several studies have demonstrated the potential benefits of early mobilization as an important component of critical care rehabilitation. However, there have been some inconsistent results. Moreover, the lack of standardized mobilization protocols and the associated safety concerns are a barrier to the implementation of early mobilization in critically ill patients. Therefore, determining the appropriate modalities of implementation of early mobilization is a key imperative to leverage its potential in these patients. In this paper, we review the contemporary literature to summarize the strategies for early mobilization of critically ill patients, assess the implementation and validity based on the International Classification of Functioning, Disability and Health, as well as discuss the safety aspects of early mobilization.

Development and validation of a nomogram for decannulation in patients with neurological injury: A prognostic accuracy study

BACKGROUND

Tracheostomy is a lifesaving procedure provided for patients with severe neurological injury. However, there is a lack of clarity about whether patients can be decannulated within 6 months in those receiving tracheostomy and what factors can be detected as a predictor for decannulation.

OBJECTIVE

The objective of this study was to explore predictive factors of decannulation in patients with neurological injury receiving tracheostomy within 6 months and construct a novel nomogram model for clinical diagnosis and treatment.

METHODS

This retrospective observational study enrolled patients with neurological injury who were admitted to the ICU of neurosurgical department in the First Affiliated Hospital of Nanjing Medical University between January 2016 and March 2021. Patients were divided into decannulation group and cannulation group according to whether tracheostomy tube removal was performed within 6 months after tracheostomy. Multivariable logistic regression analysis was performed to determine associated risk factors with a bootstrap backward selection process. The nomogram to assess the probability of decannulation at 6 months was constructed based on the regression coefficients of the associated factors and validated by bootstrap resampling. Model performance was measured by examining discrimination (Harrell's C-index), calibration (calibration plots), and utility (Kaplan-Meier curves stratified by the tertile of the predicted probability calculated and subgroup analysis stratified by age and intervention).

RESULTS

A total of 40.1% (147/367) of patients decannulated within 6 months. Significant variables in multivariable logistic regression analysis were age (odds ratio [OR], 0.972; 95% confidence interval [CI], 0.954-0.990), National Institutes of Health Stroke Scale (NIHSS) score (OR, 0.936; 95% CI, 0.911-0.963), early rehabilitation (OR, 5.062; 95% CI, 2.889-8.868), shock (OR, 0.175; 95% CI, 0.058-0.533), and secondary surgery (OR, 0.210; 95% CI, 0.078-0.566). The area under receiver operating characteristic curve estimated with these variables was of 0.793 (95% CI, 0.747-0.838; P < 0.001). A nomogram prediction model was constructed to predict the probability of decannulation in tracheostomized patients with a concordance index of 0.788 after internal validation.

CONCLUSION

We developed a nomogram that can predict the probability of decannulation within 6 months in tracheostomized neurological injury patients. The nomogram, including age, NIHSS scores, early rehabilitation, shock, and secondary surgery, may assist clinicians in estimating patients' prognosis.

Tracheostomy decannulation protocol in patients with prolonged tracheostomy referred to a rehabilitation hospital: a prospective cohort study

Background

The aim of the study was to assess the feasibility of a standardized tracheostomy decannulation protocol in patients with prolonged tracheostomy referred to a rehabilitation hospital.

Methods

This prospective cohort study recruited conscious patients with prolonged tracheostomy who were referred to the pulmonary rehabilitation department of a tertiary rehabilitation hospital between January 2019 and December 2021. A pulmonary rehabilitation team used a standardized tracheostomy decannulation protocol developed by the authors. The primary outcome was the success rate of decannulation. Secondary outcomes included decannulation time from referral and reintubation rate after a follow-up of 3 months.

Results

Of the 115 patients referred for weaning from mechanical ventilation and tracheostomy decannulation over the study period, 80.0% (92/115) were finally evaluated for tracheostomy decannulation. The mean time of tracheostomy in patients transferred to our department was 70.6 days. After assessment by a multidisciplinary team, 57 patients met all the decannulation indications and underwent decannulation. Fifty-six cases were successful, and 1 case was intubated again. The median time to decannulation after referral was 42.7 days. Reintubation after a follow-up of 3 months did not occur in any patients.

Conclusions

A standardized tracheostomy decannulation protocol implemented by a pulmonary rehabilitation team is associated with successful tracheostomy decannulation in patients with prolonged tracheostomy. Not every tracheostomy patient must undergo upper airway endoscopy before decannulation. Tolerance of speaking valve continuously for 4 h can be used as an alternative means for tube occlusion. A swallow assessment was used to evaluate the feeding mode and did not affect the final decision to decannulate.

Trial registration: 2018bkky-121.

Gram-negative multidrug-resistant organisms were dominant in neurorehabilitation ward patients in a general hospital in southwest China

This study aimed to investigate the prevalence of and risk factors for multidrug-resistant organism (MDRO) infection in the rehabilitation ward of a general hospital in Southwest China. We analyzed rehabilitation patients with nosocomial infections caused by MDROs from June 2016 to June 2020. MDRO infection pathogens and associated antibiotic resistance were calculated. Possible risk factors for MDRO-related infection in the neurorehabilitation ward were analyzed using chi-square, and logistic regression. A total of 112 strains of MDRO were found positive from 96 patients. The MDRO test-positive rate was 16.70% (96/575). Ninety-five MDRO strains were detected in sputum, of which 84.82% (95/112) were gram-negative bacteria. Acinetobacter baumannii (A. Baumannii), Pseudomonas aeruginosa (P. aeruginosa), and Klebsiella pneumonia (K. pneumonia) were the most frequently isolated MDRO strains. The logistic regression model and multifactorial analysis showed that long-term (≥ 7 days) antibiotic use (OR 6.901), history of tracheotomy (OR 4.458), and a low albumin level (< 40 g/L) (OR 2.749) were independent risk factors for the development of MDRO infection in patients in the rehabilitation ward (all P < 0.05). Gram-negative MRDOs were dominant in rehabilitation ward patients. Low albumin, history of a tracheostomy, and long-term use of antibiotics were independent risk factors for MRDO infection and are worthy of attention.

Early Neurorehabilitation and Recovery from Disorders of Consciousness After Severe COVID-19

BACKGROUND

Early neurorehabilitation improves outcomes in patients with disorders of consciousness (DoC) after brain injury, but its applicability in COVID-19 is unknown. We describe our experience implementing an early neurorehabilitation protocol for patients with COVID-19-associated DoC in the intensive care unit (ICU) and evaluate factors associated with recovery.

METHODS

During the initial COVID-19 surge in New York City between March 10 and May 20, 2020, faced with a disproportionately high number of ICU patients with prolonged unresponsiveness, we developed and implemented an early neurorehabilitation protocol, applying standard practices from brain injury rehabilitation care to the ICU setting. Twenty-one patients with delayed recovery of consciousness after severe COVID-19 participated in a pilot early neurorehabilitation program that included serial Coma Recovery Scale-Revised (CRS-R) assessments, multimodal treatment, and access to clinicians specializing in brain injury medicine. We retrospectively compared clinical features of patients who did and did not recover to the minimally conscious state (MCS) or better, defined as a CRS-R total score (TS) ≥ 8, before discharge. We additionally examined factors associated with best CRS-R TS, last CRS-R TS, hospital length of stay, and time on mechanical ventilation.

RESULTS

Patients underwent CRS-R assessments a median of six (interquartile range [IQR] 3-10) times before discharge, beginning a median of 48 days (IQR 40-55) from admission. Twelve (57%) patients recovered to MCS after a median of 8 days (IQR 2-14) off continuous sedation; they had lower body mass index (p = 0.009), lower peak serum C-reactive protein levels (p = 0.023), higher minimum arterial partial pressure of oxygen (p = 0.028), and earlier fentanyl discontinuation (p = 0.018). CRS-R scores fluctuated over time, and the best CRS-R TS was significantly higher than the last CRS-R TS (median 8 [IQR 5-23] vs. 5 [IQR 3-18], p = 0.002). Earlier fentanyl (p = 0.001) and neuromuscular blockade (p = 0.015) discontinuation correlated with a higher last CRS-R TS.

CONCLUSIONS

More than half of our cohort of patients with prolonged unresponsiveness following severe COVID-19 recovered to MCS or better before hospital discharge, achieving a clinical benchmark known to have relatively favorable long-term prognostic implications in DoC of other etiologies. Hypoxia, systemic inflammation, sedation, and neuromuscular blockade may impact diagnostic assessment and prognosis, and fluctuations in level of consciousness make serial assessments essential. Early neurorehabilitation of these patients in the ICU can be accomplished but is associated with unique challenges. Further research should evaluate factors associated with longer-term neurologic recovery and benefits of early rehabilitation in patients with severe COVID-19.

Factors Influencing Functional Recovery during Rehabilitation after Severe Acquired Brain Injuries: A Retrospective Analysis

Severe acquired brain injuries (sABI) represent one of the main causes of disability and limitation in social life participation that need an intensive rehabilitation approach. The purpose of this study was to identify a possible correlation between different supposed conditioning factors and the efficiency of rehabilitation interventions. In this retrospective study, data were processed regarding 44 patients admitted to a neurorehabilitation department after sABI. A significant correlation with the efficiency of the rehabilitation intervention (expressed as the variation of the Barthel score between discharge and admittance in relation to the duration of the rehabilitative hospitalization) was found for both the etiology of the brain injury (p = 0.023), the precocity of the rehabilitation treatment (p = 0.0475), the presence of a tracheal cannula (p = 0.0084) and forms of nutrition other than oral (p < 0.0001). The results of this study suggest that improving the management of the respiratory system, swallowing and nutritional aspects, and favoring an early and personalized rehabilitation treatment, can help to optimize the overall care of patients suffering from sABI, thus allowing a reduction in complications, improvement in functional recovery and ensuring a better management of economic, social and health resources.

External Validation and Calibration of the DecaPreT Prediction Model for Decannulation in Patients with Acquired Brain Injury

We propose a new set of clinical variables for a more accurate early prediction of safe decannulation in patients with severe acquired brain injury (ABI), during a post-acute rehabilitation course. Starting from the already validated DecaPreT scale, we tested the accuracy of new logistic regression models where the coefficients of the original predictors were reestimated. Patients with tracheostomy were retrospectively selected from the database of the neurorehabilitation unit at the S. Anna Institute of Crotone, Italy. New potential predictors of decannulation were screened from variables collected on admission during clinical examination, including (a) age at injury, (b) coma recovery scale-revised (CRS-r) scores, and c) length of ICU period. Of 273 patients with ABI (mean age 53.01 years; 34% female; median DecaPreT = 0.61), 61.5% were safely decannulated before discharge. In the validation phase, the linear logistic prediction model, created with the new multivariable predictors, obtained an area under the receiver operating characteristics curve of 0.901. Our model improves the reliability of simple clinical variables detected at the admission of the post-acute phase in predicting decannulation of ABI patients, thus helping clinicians to plan better rehabilitation.

The tracheotomy tube weaning in patients with severe acquired brain injury: comparison of two operative procedures in a postacute rehabilitation hospital

BACKGROUND

Despite the high frequency of tracheotomy in severe acquired brain injury (sABI) patients, available literature about the weaning procedure is mainly represented by expert opinions with no standardized and evidence-based criteria.

AIM

The Institute of Physical and Rehabilitation Medicine "Gervasutta" adopted a new decannulation procedure, recommended by the Italian Society of Physical Medicine and Rehabilitation (SIMFER). This study evaluates whether the new procedure helps to improve the decannulation process of sABI patients.

DESIGN

A prospective observational with historical control was performed by dividing sABI patients into two groups depending on whether they were treated with or without the new procedure.

SETTING

The Department of Neurorehabilitation of the Institute of Physical and Rehabilitation Medicine "Gervasutta" in Udine, Italy.

POPULATION

sABI patients with tracheal cannula admitted to the Institute of Physical and Rehabilitation Medicine "Gervasutta" from January 2015 to March 2019.

METHODS

Clinical data were collected as both process and outcome indicators before and after the adoption of the new procedure. Data have been processed with Simple Interactive Statistical Analysis (SISA; Irving, TX, USA) software.

RESULTS

A sample of 141 patients was analysed. Among the 141 patients, 57 (40.4%) were treated with the new procedure. No differences were found between the two groups in terms of complications, functional independence measure (FIM), or level of cognitive functioning (LCF) at the admission. When the new procedure was applied, the decannulation rate was significantly higher (OR=1.8; 95% CI=1.2-9.8; P=0.01) and the time (days) between admission and oral feeding resumption was significantly lower (P<0.001; 95% CI=-10, -34 days).

CONCLUSIONS

The introduction of the new protocol allowed the safe achievement of both oral feeding resumption and decannulation, which are two of the main early rehabilitation goals.

CLINICAL REHABILITATION IMPACT

The standardization of the decannulation process has determined the achievement of a significantly faster oral feeding resumption and an increase in the decannulation rate during the rehabilitation of sABI patients.

Paths to Successful Translation of New Therapies for Severe Traumatic Brain Injury in the Golden Age of Traumatic Brain Injury Research: A Pittsburgh Vision

New neuroprotective therapies for severe traumatic brain injury (TBI) have not translated from pre-clinical to clinical success. Numerous explanations have been suggested in both the pre-clinical and clinical arenas. Coverage of TBI in the lay press has reinvigorated interest, creating a golden age of TBI research with innovative strategies to circumvent roadblocks. We discuss the need for more robust therapies. We present concepts for traditional and novel approaches to defining therapeutic targets. We review lessons learned from the ongoing work of the pre-clinical drug and biomarker screening consortium Operation Brain Trauma Therapy and suggest ways to further enhance pre-clinical consortia. Biomarkers have emerged that empower choice and assessment of target engagement by candidate therapies. Drug combinations may be needed, and it may require moving beyond conventional drug therapies. Precision medicine may also link the right therapy to the right patient, including new approaches to TBI classification beyond the Glasgow Coma Scale or anatomical phenotyping-incorporating new genetic and physiologic approaches. Therapeutic breakthroughs may also come from alternative approaches in clinical investigation (comparative effectiveness, adaptive trial design, use of the electronic medical record, and big data). The full continuum of care must also be represented in translational studies, given the important clinical role of pre-hospital events, extracerebral insults in the intensive care unit, and rehabilitation. TBI research from concussion to coma can cross-pollinate and further advancement of new therapies. Misconceptions can stifle/misdirect TBI research and deserve special attention. Finally, we synthesize an approach to deliver therapeutic breakthroughs in this golden age of TBI research.

Management of tracheostomized patients after poor grade subarachnoid hemorrhage: Disease related and pulmonary risk factors for failed and delayed decannulation

OBJECTIVE

Tracheostomy is often indicated in patients with spontaneous subarachnoid hemorrhage (sSAH). Decannulation is a major goal of neurorehabilitation, but cannot be achieved in all patients. The aim of this study was to describe the course of decannulation and to identify associated risk factors in a single-center collective.

PATIENTS AND METHODS

We retrospectively reviewed 87 sSAH patients with WFNS (World Federation of Neurosurgical Societies) grade III-IV, who received tracheostomy. Decannulation events and the time from tracheostomy to decannulation were recorded in a 200-days follow-up. Variables analyzed were: age, sex, WFNS grade, Fisher grade, the presence of intracerebral or intraventricular hematoma, acute hydrocephalus, aneurysm location, aneurysm obliteration (surgical vs. endovascular), treatment related complications, decompressive craniectomy, symptomatic cerebral vasospasm, vasospasm-related infarction and timing of tracheostomy. Further risk factors analyzed were preexisting chronic lung disease and pneumonia. Functional outcome was assessed by the modified Rankin Scale (mRS).

RESULTS

The rate of successful decannulation was 84% after a median of 47 days. A higher WFNS grade and pneumonia were associated with both a prolonged time to decannulation (TTD) and decannulation failure (DF). Older age (> 60 years) and necessity for decompressive craniectomy were only associated with prolonged TTD. Outcome analysis revealed that patients with DF show a significantly (p < 0.01) higher rate of unfavorable outcome (mRS 3-6).

CONCLUSION

Successful decannulation is possible in the majority of sSAH patients and particularly, in all patients with WFNS grade III. WFNS grading, age, the necessity for decompressive craniectomy and pneumonia are significantly associated with the TTD. WFNS grade and pneumonia are significantly associated with DF. The mean cannulation time of sSAH patients is shorter in relation to stroke patients.