Race is a Predictor of Withdrawal of Life Support in Patients with Intracerebral Hemorrhage

Introduction: Medical and socioeconomic factors may impact decisions to change the goals of care for patients with intracerebral hemorrhage (ICH) to comfort measures only. Methods: We reviewed prospectively collected data on patients with ICH, including baseline patient demographics, Glasgow Coma Scale (GCS), National Institute of Health Stroke Scale (NIHSS), and ICH score. We conducted multivariable logistic regression analysis to identify predictors of change to comfort measures only status. Results: Of 198 patients included in the analysis, 39 (19.7%) were made comfort measures only. Age, gender, insurance status, substance use, and medical comorbidities were similar between groups. Race was significantly different between the comfort measures only (black 15.4%, white 51.3%, other 33.3%) and noncomfort measures only groups (black 39.6%, white 45.9%, other 14.5%; P?=?.003). Patients changed to comfort measures only had higher mean income based on zip code ($59,264 versus $49,916; P?=?.021), higher median NIHSS (23 versus 16; P?=?.0001), higher ICH score (2.7 versus 1.5; P < .0001), lower median GCS (7 versus 13; P < .0001). Following multivariable analysis, factors associated with comfort measures only were GCS odds ratio (OR) 0.77, 95% confidence interval (CI) 0.68-0.86, P < .0001), intraventricular hemorrhage (IVH) volume (OR 1.03, 95% CI 1.01-1.06, P?=?.002), and black race (OR 0.24, 95% CI 0.07-0.82, P?=?.022). Mortality, poor outcome, and hospital length of stay were not significantly different between black and white patients. Conclusions: Lower GCS score, higher IVH volume, and race were independent predictors of comfort measures only. Black patients were 76% less likely to withdraw life support than white patients. There were no significant differences in mortality between black and white patients. Providers should be aware of potential racial disparities.     

Hyperglycemia and Short-term Outcome in Patients with Spontaneous Intracerebral Hemorrhage

Background  Hyperglycemia has a detrimental effect in several acute neurological critical illnesses. No consensus exists on the optimal management of hyperglycemia in spontaneous intracerebral hemorrhage (sICH). Our aim was to determine whether blood glucose (BG) would predict 30-day mortality in sICH. Methods  All patients with a well-defined diagnosis of sICH admitted into 24 h in three primary referred centers were included in this prospective observational follow-up study. Patients had extensive monitoring of BG values and those with BG values >8.29 mmol/l (150 mg/dl) received a variable intravenous insulin dose to maintain BG concentrations during the first 72 h after sICH between 3.32 and 8.29 mmol/l (60–150 mg/dl) using pre-specified insulin dosing schedule protocol. Results  Between January 1, 2002, and December 31, 2003, 295 consecutive patients (mean ± SD age 66 ± 12 years) were prospectively included. A 1.0 mmol/l (18 mg/dl) increase in the BG concentration at admission was associated with a 33% mortality increase (OR: 1.33; 95%CI: 1.22–1.46; P < 0.0001). Adjusting for demographics, risk factors, stroke severity, and surgery there was no change in the increased risk. During the first 12 h after sICH, the insulin treatment protocol was enabling to reduce mortality (OR: 1.36, 95%CI: 1.14–1.61; P = 0.0005, per 1 IU increase) while thereafter this association was greatly attenuated and not more significant. Conclusions  Hyperglycemia is a common condition after sICH and may worsen prognosis. Very early insulin therapy apparently does not improve prognosis. These results raise concern about routine clinical practice implementation of this intervention without any evidence from randomized trials.     

The Spot Sign Predicts Hematoma Expansion,Outcome, and Mortality in Patients with Primary Intracerebral Hemorrhage

Objective

The purpose of this study was to retrospectively review cases of intracerebral hemorrhage (ICH) medically treated at our institution to determine if the CT angiography (CTA) ''spot sign'' predicts in-hospital mortality and clinical outcome at 3 months in patients with spontaneous ICH.

Methods

We conducted a retrospective review of all consecutive patients who were admitted to the department of neurosurgery. Clinical data of patients with ICH were collected by 2 neurosurgeons blinded to the radiological data and at the 90-day follow-up.

Results

Multivariate logistic regression analysis identified predictors of poor outcome; we found that hematoma location, spot sign, and intraventricular hemorrhage were independent predictors of poor outcome. In-hospital mortality was 57.4% (35 of 61) in the CTA spot-sign positive group versus 7.9% (10 of 126) in the CTA spot-sign negative group. In multivariate logistic analysis, we found that presence of spot sign and presence of volume expansion were independent predictors for the in-hospital mortality of ICH.

Conclusion

The spot sign is a strong independent predictor of hematoma expansion, mortality, and poor clinical outcome in primary ICH. In this study, we emphasized the importance of hematoma expansion as a therapeutic target in both clinical practice and research.     

新型脑出血临床评估量表

自2001年首个脑出血（intracerebral hemorrhage,ICH）预后评估量表问世以来,其临床有效性得到了充分的外部验证。但毕竟原始脑出血（original ICH,oICH）评分量表是设计来评价30 d死亡事件的,并没有包括诸多与预后密切相关的因子,因此对功能预后的预测准确率欠佳。为了预测ICH患者的功能预后,一系列新型评测体系被建立起来。本文主要针对现有的新型ICH评估量表从研究背景、方法学、评估指标、外部验证等几个方面进行综述,以期阐明其适用范围和临床效度,为临床医师按需选择提供参考。     

Predictors of 30-Day Mortality and 90-Day Functional Recovery after Primary Intracerebral Hemorrhage : Hospital Based Multivariate Analysis in 585 Patients

Objective

The purpose of this study was to identify independent predictors of mortality and functional recovery in patients with primary intracerebral hemorrhage (PICH) and to improve functional outcome in these patients.

Methods

Data were collected retrospectively on 585 patients with supratentorial PICH admitted to the Stroke Unit at our hospital between 1st January 2004 and the 31st July 2008. Using multivariate logistic regression analysis, the associations between all selected variables and 30-day mortality and 90-day functional recoveries after PICH was evaluated.

Results

Ninety-day functional recovery was achieved in 29.1% of the 585 patients and 30-day mortality in 15.9%. Age (OR=7.384, p=0.000), limb weakness (OR=6.927, p=0.000), and hematoma volume (OR=5.293, p=0.000) were found to be powerful predictors of 90-day functional recovery. Furthermore, initial consciousness (OR=3.013, p=0.014) hematoma location (lobar, OR=2.653, p=0.003), ventricular extension of blood (OR=2.077, p=0.013), leukocytosis (OR=2.048, p=0.008), alcohol intake (drinker, OR=1.927, p=0.023), and increased serum aminotransferase (OR=1.892, p=0.035) were found to be independent predictors of 90-day functional recovery after PICH. On the other hand, a pupillary abnormality (OR=4.532, p=0.000) and initial unconsciousness (OR=3.362, p=0.000) were found to be independent predictors of 30-day mortality after PICH.

Conclusion

The predictors of mortality and functional recovery after PICH identified during this analysis may assist during clinical decision-making, when advising patients or family members about the prognosis of PICH and when planning intervention trials.     

Effect of Treatment of Elevated Blood Pressure on Neurological Deterioration in Patients with Acute Intracerebral Hemorrhage

Introduction  Treatment of elevated blood pressure after acute intracerebral hemorrhage (ICH) is controversial. There is a risk of hematoma expansion with elevated blood pressure, and risk of ischemia with blood pressure control. This study was done to determine the effect of blood pressure control on outcome. Methods  We retrospectively studied 122 patients with ICH. We collected 24-h blood pressure readings on all patients. The Glasgow Coma Score (GCS) at baseline and at 24 h was used to determine neurological deterioration (GCS decline ≥ 2). Baseline computerized tomography (CT) scans were reviewed for hematoma volume, intraventricular hemorrhage, and location of hemorrhage. Drops in systolic blood pressure and mean arterial pressures over 24 h were divided in quartiles to determine the risk of neurological deterioration among quartiles. A logistic regression model was used to determine the association between variables of interest and neurological deterioration. Results  Neurological deterioration was observed in 12 patients (10%). Baseline blood pressure and GCS were only two variables significantly different among quartiles of blood pressure drop. Multivariable adjusted analysis for these variables demonstrated significant trend toward reduced neurological deterioration with maximum blood pressure drop (systolic or mean). The risk of neurological deterioration was significantly lower in the quartile of maximum drop of systolic (odds ratio [OR] 0.02, 95% confidence interval [CI] 0.0–0.68) or mean (OR 0.03, 95% CI 0.0–0.98) blood pressure when compared to the quartile with least drop. Conclusion  This study supports that reduction of blood pressure in patients with acute ICH is safe and suggests that aggressive reduction might reduce the risk of neurological deterioration in first 24 h of admission.     

A Case of Temporal Intracerebral Hemorrhage That Presented with Sudden Bilateral Hearing Loss as the Initial Symptom

A 57-year-old man presented to the outpatient department with sudden bilateral hearing loss. The otological examination suggested bilateral severe sensorineural hearing loss. After several hours, the patient complained of a headache and became drowsy. The brain computed tomography showed a 3 × 4 cm intracerebral hemorrhage (ICH) of the left temporal lobe. Surgery was performed and 34 days after the procedure the patient was discharged from the hospital with severe bilateral sensorineural hearing loss (SNHL). Temporal lobe ICH should be considered in the differential diagnosis of patients with sudden bilateral hearing loss, regardless of the other neurological symptoms.     

Association and Clinical Outcomes of Marijuana in Patients with Intracerebral Hemorrhage

Objective

An epidemiological relationship between intracerebral hemorrhage (ICH) and marijuana use is not known. Data about the impact of marijuana on ICH patient's outcomes remain scarce.

脑出血的经典临床评测量表及改良

脑出血（intracerebral hemorrhage,ICH）是最为严重的卒中类型,致死、致残率甚高。ICH的评估量表对于制定标准化临床治疗方案,评价不同研究间的均衡性至关重要。自2001年首个ICH评估量表问世以来,其有效性得到了充分的外部验证;并有多项研究致力于通过改良这一量表来提供更优秀的ICH预后评测工具。本文主要针对经典的原始脑出血评分（the original ICH,oICH）及其改良量表从研究背景、方法学、评估指标、外部验证等几个方面进行综述,以期阐明其适用范围和临床效度,为临床医师按需选择提供参考。     

Impact of Early Enteral Nutrition on In-Hospital Mortality in Patients with Hypertensive Intracerebral Hemorrhage

Objective

We conducted this study to evaluate the clinical impact of early enteral nutrition (EN) on in-hospital mortality and outcome in patients with critical hypertensive intracerebral hemorrhage (ICH).

Methods

We retrospectively analyzed 123 ICH patients with Glasgow Coma Scale (GCS) score of 3-12. We divided the subjects into two groups : early EN group (< 48 hours, n = 89) and delayed EN group (≥ 48 hours, n = 34). Body weight, total intake and output, serum albumin, C-reactive protein, infectious complications, morbidity at discharge and in-hospital mortality were compared with statistical analysis.

Results

The incidence of nosocomial pneumonia and length of intensive care unit stay were significantly lower in the early EN group than in the delayed EN group (p < 0.05). In-hospital mortality was less in the early EN group than in the delayed EN group (10.1% vs. 35.3%, respectively; p = 0.001). By multivariate analysis, early EN [odds ratio (OR) 0.229, 95% CI : 0.066-0.793], nosocomial pneumonia (OR = 5.381, 95% CI : 1.621-17.865) and initial GCS score (OR = 1.482 95% CI : 1.160-1.893) were independent predictors of in-hospital mortality in patients with critical hypertensive ICH.

Conclusion

These findings indicate that early EN is an important predictor of outcome in patients with critical hypertensive ICH.     

Warfarin-Induced Intracerebral Hemorrhage Associated with Microbleeds

Background

Microbleeds (MBs), proposed as a biomarker for microangiopathy, have been suggested as a predictor of spontaneous or thrombolysis-related intracerebral hemorrhage (ICH) in acute ischemic stroke. However, the relationship between MBs and warfarin-induced ICH is not clear.

Case Report

We describe two patients who developed warfarin-induced ICH at the site of MBs documented in previous MRI.

Conclusions

The presence of MBs might increase the risk of ICH after warfarin use in ischemic stroke patients. A large cohort study is required to confirm the relationship of MBs with warfarin-induced ICH.     

幕上自发性脑出血患者痫性发作的发生率及其相关因素分析——来自中国国家卒中登记数据库

【摘要】 目的 评价幕上自发性脑出血患者伴发痫性症状的发生率以及其相关危险因素。 方法 本研究为前瞻性队列研究,纳入2007年9月～2008年8月中国国家卒中登记数据库的2862例既 往无癫痫病史的发病14 d内住院的幕上自发性脑出血患者。住院时记录患者发病时或住院期间是否 合并痫性发作症状,根据是否合并痫性发作分为合并痫性发作组和未合并痫性发作组,比较两组 患者的基本特征。采用多因素回归模型评价患者的人口学特征、既往史、入院时格拉斯哥昏迷量表 （Glasgow Coma Scale,GCS）评分、幕上脑出血累及部位和体积、住院合并症与痫性发作的相关性。 结果 2862例幕上自发性脑出血患者,年龄中位数62.0岁（四分位间距53.0～72.0）,1115例（39.0%）为 女性,1921例（67.1%）既往有高血压病史。133例（4.6%）患者合并痫性发作。与未合并痫性发作患者相 比,合并痫性发作患者GCS平均评分低（9.5 vs 12.5,P =0.006）,合并脑积水（5.3% vs 1.5%,P =0.050） 和肺炎（30.1% vs 17.0%,P＜0.001）的比例高。在多因素回归分析中,下列因素与幕上自发性脑出血 患者伴发痫性发作独立相关：入院时GCS评分每降低2分［比值比（odds ratio,OR）1.32,95%可信区间 （confidence interval,CI）1.21～1.45］、血肿累及皮层（OR 5.82,95%CI 3.88～8.72）、合并脑积水（OR 2.73, 95%CI 1.14～6.56）和合并肺炎（OR 1.65,95%CI 1.09～2.52）。 结论 痫性发作是幕上自发性脑出血患者较为常见的神经系统并发症。昏迷程度、血肿累及皮层, 以及合并脑积水和肺炎是并发痫性发作症状的危险因素。     

高血压脑出血卒中后抑郁风险因素相关性研究

目的 探讨高血压脑出血患者卒中后抑郁相关影响因素。方法 前瞻性录入65例急性高血压脑出血患者临床和计算机断层扫描（computer tomography,CT）影像资料,评估患者发病14d和3个月卒中后抑郁发生情况及生存质量状况,对临床资料和CT影像特征与卒中后抑郁的关系进行单因素和多因素分析。结果 65例患者中有57例完成14d随访,53例完成3个月随访。脑出血发病14d和3个月卒中后抑郁的发生率分别为35.1%和38.9％。单因素分析显示入院后首次美国国立卫生研究院卒中量表评分（thenational institutes of health stroke scale, NIHSS）与高血压脑出血发病后14d卒中后抑郁相关（P =0.027）。性别、出血部位和出血量与脑出血发病后3个月卒中后抑郁相关：与非抑郁组比较,抑郁组患者男性比例较低（P =0.038）,基底节出血比例较高（P =0.031）,平均出血量大（P =0.046）。多因素分析显示出血量是高血压脑出血患者发病3个月卒中后抑郁的风险预测因素（P =0.049）。结论 NIHSS评分和CT影像特征可作为高血压脑出血卒中后抑郁的评价指标,将CT影像与神经功能缺损程度评分有机结合可为脑出血综合性治疗策略的建立提供客观依据。