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Research Article
March 16, 2023
editorial

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

May 9, 2023 issue
100 (19) e1985-e1995

Abstract

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.

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Letters to the Editor
14 April 2023
Reader Response: Functional outcomes and mortality in patients with intracerebral hemorrhage after intensive medical and surgical support
Vishank A Shah, MD; Assistant Professor of Neurology, Staff Neurointensivist | Johns Hopkins University School of Medicine
Lourdes Carhuapoma, MS, CRNP, CCRN, PhD; Neurocritical Care Nurse Practitioner | Johns Hopkins University School of Medicine
Daniel F Hanley, MD; Professor of Neurology | Johns Hopkins University School of Medicine
Wendy C Ziai, MD, MPH; Professor of Neurology, Staff Neurointensivist | Johns Hopkins University School of Medicine

Abulhasan et al. reported unfavorable outcomes in ICH patients despite ‘aggressive’ treatment and concluded that poor outcomes in ICH are related to the primary insult, not a consequence of premature termination of medical care.1 The conclusion is concerning as it suggests that aggressive treatment of ICH may not improve outcome.

The authors concluded that surgical intervention did not improve functional outcomes. However, the retrospective design, selection bias related to surgical indication, small number of surgical patients after propensity-score matching, and assessment of short-term outcomes limit the interpretation of these results. ICH patients have slow recovery trajectories, with functional recovery occurring up to 12 months.2 Response to ICH treatment within 30-days have demonstrated a strong association with long-term functional recovery.2

Importantly, patients with withdrawal-of-life-sustaining-treatment (WLST) after 72 hours were included in the ‘aggressively’ treated cohort and the impact of WLST was not studied. This raises concerns regarding the influence of WLST on unfavorable outcomes, which perpetuates the ‘self-fulfilling prophecy’ that has clouded ICH care for over two decades.3

We urge caution in utilizing these results for treatment decisions in individual ICH patients. These data are insufficient to inform decisions about routine practice standards. Longer periods of supportive care are warranted to optimize ICH outcomes.

1. Abulhasan YB, Teitelbaum J, Al-Ramadhani Dabr-Nr K, Morrison AStat KT, Angle MR. Functional outcomes and mortality in patients with intracerebral hemorrhage after intensive medical and surgical support. Neurology. 2023. https://www.ncbi.nlm.nih.gov/pubmed/36927881.

2. Shah VA, Thompson RE, Yenokyan G, et al. One-year outcome trajectories and factors associated with functional recovery among survivors of intracerebral and intraventricular hemorrhage with initial severe disability. Archives of neurology (Chicago). 2022;79(9):856-868. http://dx.doi.org/10.1001/jamaneurol.2022.1991. doi: 10.1001/jamaneurol.2022.1991.

3. BECKER KJ, BAXTER AB, COHEN WA, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology. 2001;56(6):766-772. https://www.ncbi.nlm.nih.gov/pubmed/11274312. doi: 10.1212/WNL.56.6.766.

Author disclosures are available upon request([email protected]).

10 May 2023
Author Response: Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support
Yasser B. Abulhasan, MBChB, FRCPC, Staff Neurointensivist | Kuwait University
Jeanne Teitelbaum, MD, FRCPC, Staff Neurointensivist | McGill University
Khalsa Al-Ramadhani, MD, DABR-NR, Neuroradiologist | McGill University
Kathryn T. Morrison, PhD, AStat, Statistician | McGill University
Mark R. Angle, MD, Staff Neurointensivist | McGill University

We thank Drs. Shah, Carhuapoma, Hanley, and Ziai for their comments. Our paper is an analysis of ICH outcomes in a real-world setting.1 We agree that it should inform, not determine current practice, much as did the original ICH score paper.2

We too were disappointed that our demonstrated aggressivity and avoidance of early-care-limitations (ECL) did not result in substantial improvements in 90-day outcomes. We don't believe there were confounding 'self-fulfilling prophecies.'

While patients may improve after longer periods of observation, this would require a prospective trial of uncurated ICH patients to quantify it. The only comparable paper showed most improvement at 90-days, and little between 90-days and 1-year.3

As to withdrawal-of-life-sustaining-treatment, we believe that the testable question is whether early, and so potentially premature, care limitations produce unnecessary poor outcomes. Our analysis of the no-ECL cohort didn't confirm this hypothesis (eTables 1&16).

Our surgical results focus on moribund patients, previously unreported. The decrease in early mortality, without altering late outcomes, mirrors that of all previous surgical interventions in other populations.

Finally, we believe that it would be a mistake to discount disappointing results. The statement that 'longer periods of supportive care are warranted to optimize ICH outcomes', remains a hypothesis to be proven.

References:

1. Abulhasan YB, Teitelbaum J, Al-Ramadhani K, Morrison KT, Angle MR. Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support. Neurology. 2023;100(19):e1985-e1995.

2. Hemphill JC, 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC. The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke. 2001;32(4):891-897.

3. Hemphill JC, 3rd, Farrant M, Neill TA, Jr. Prospective validation of the ICH Score for 12-month functional outcome. Neurology. 2009;73(14):1088-1094.

I am an Author of this Work, and the Work was prepared on my own time - not as part of my duties as an employee.

Information & Authors

Information

Published In

Neurology®
Volume 100Number 19May 9, 2023
Pages: e1985-e1995
PubMed: 36927881

Publication History

Received: July 17, 2022
Accepted: January 17, 2023
Published online: March 16, 2023
Published in print: May 9, 2023

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Disclosure

Y.B. Abulhasan, J. Teitelbaum, and K. Al-Ramadhani report no disclosures relevant to the manuscript. K.T. Morrison is the President and Co-Founder of Precision Analytics Inc. M.R. Angle reports no disclosures relevant to the manuscript. Go to Neurology.org/N for full disclosures.

Study Funding

No targeted funding reported.

Authors

Affiliations & Disclosures

Yasser B. Abulhasan, MBChB, FRCPC https://orcid.org/0000-0003-2456-3847
From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada.
Disclosure
Scientific Advisory Boards:
1.
None
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
None
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
None
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Jeanne Teitelbaum, MD, FRCPC
From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada.
Disclosure
Scientific Advisory Boards:
1.
None
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
None
Editorial Boards:
1.
Canadian Journal of Neurologic Sciences, associate editor, 2 years
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
None
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Khalsa Al-Ramadhani, MD, DABR-NR
From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada.
Disclosure
Scientific Advisory Boards:
1.
None
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
None
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
None
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Kathryn T. Morrison, PhD, AStat
From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada.
Disclosure
Scientific Advisory Boards:
1.
None
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
None
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
KT Morrison is the President and Co-Founder of Precision Analytics Inc, from 2017 to present.
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
None
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE
Mark R. Angle, MD
From the Neurological Intensive Care Unit (Y.B.A., J.T., M.R.A.) and Department of Radiology (K.A.R.), Montreal Neurological Institute and Hospital, McGill University, Quebec, Canada; Faculty of Medicine (Y.B.A.), Health Sciences Center, Kuwait University; and Department of Epidemiology, Biostatistics and Occupational Health (K.T.M.), McGill University, Montreal, Quebec, Canada.
Disclosure
Scientific Advisory Boards:
1.
None
Gifts:
1.
NONE
Funding for Travel or Speaker Honoraria:
1.
None
Editorial Boards:
1.
NONE
Patents:
1.
NONE
Publishing Royalties:
1.
NONE
Employment, Commercial Entity:
1.
NONE
Consultancies:
1.
NONE
Speakers' Bureaus:
1.
NONE
Other Activities:
1.
NONE
Clinical Procedures or Imaging Studies:
1.
NONE
Research Support, Commercial Entities:
1.
NONE
Research Support, Government Entities:
1.
NONE
Research Support, Academic Entities:
1.
NONE
Research Support, Foundations and Societies:
1.
None
Stock/stock Options/board of Directors Compensation:
1.
NONE
License Fee Payments, Technology or Inventions:
1.
NONE
Royalty Payments, Technology or Inventions:
1.
NONE
Stock/stock Options, Research Sponsor:
1.
NONE
Stock/stock Options, Medical Equipment & Materials:
1.
NONE
Legal Proceedings:
1.
NONE

Notes

Correspondence Dr. Abulhasan [email protected]
Go to Neurology.org/N for full disclosures. Funding information and disclosures deemed relevant by the authors, if any, are provided at the end of the article.
Submitted and externally peer reviewed. The handling editor was Editor-in-Chief José Merino, MD, MPhil, FAAN.

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Cited By
  1. Reader Response: Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support, Neurology, 101, 12, (547-547), (2023)./doi/10.1212/WNL.0000000000207787
    Abstract
  2. Author Response: Functional Outcomes and Mortality in Patients With Intracerebral Hemorrhage After Intensive Medical and Surgical Support, Neurology, 101, 12, (547-548), (2023)./doi/10.1212/WNL.0000000000207786
    Abstract
  3. Maximal Care After Intracerebral Hemorrhage, Neurology, 100, 19, (891-892), (2023)./doi/10.1212/WNL.0000000000207206
    Abstract
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