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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.
Glossary
- AUC=
- area under the curve;
- BP=
- blood pressure;
- CTA=
- CT angiography;
- ECL=
- early care limitation;
- ED=
- emergency department;
- GCS=
- Glasgow Coma Scale;
- ICH=
- intracerebral hemorrhage;
- ICU=
- intensive care unit;
- IQR=
- interquartile range;
- IVH=
- intraventricular hemorrhage;
- mRS=
- modified Rankin Scale;
- NCCU=
- neurocritical care unit;
- OR=
- odds ratio;
- ROC=
- receiver operating characteristic;
- SBP=
- systolic blood pressure;
- tPA=
- tissue plasminogen activator
Footnotes
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.
See page 891
- Received July 17, 2022.
- Accepted in final form January 17, 2023.
- © 2023 American Academy of Neurology
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