Early care limitations independently predict mortality after intracerebral hemorrhage.

OBJECTIVE: Intracerebral hemorrhage (ICH) is associated with a high early mortality rate. We examined the impact of early do not resuscitate (DNR) orders and other limitations in aggressive care on mortality after ICH in a community-based study. METHODS: Cases of spontaneous ICH from 2000 to 2003 were identified from the Brain Attack Surveillance in Corpus Christi (BASIC) project, with deaths ascertained through 2005. Charts were reviewed for early (<24 hours from presentation) DNR orders, withdrawal of care, or deferral of other life sustaining interventions, analyzed together as combined DNR (C-DNR). Multivariable Cox-proportional hazards models were used to examine the association between short- and long-term all-cause mortality and early C-DNR, adjusted for demographics and established predictors of mortality after ICH. RESULTS: Of 18,393 subjects screened for cerebrovascular disease, 270 non-traumatic ICH cases were included. Cumulative mortality risk was 0.43 at 30 days and 0.55 over the study course. Early C-DNR was noted in 34% of cases and was associated with a doubling in the hazard of death both at 30 days (hazard ratio [HR] 2.17, 95% CI 1.38, 3.41) and at end of follow-up (HR 1.92, 95% CI 1.29, 2.87) despite adjustment for age, gender, ethnicity, Glasgow Coma Scale, ICH volume, intraventricular hemorrhage, and infratentorial hemorrhage. CONCLUSIONS: Early care limitations are independently associated with both short- and long-term all-cause mortality after intracerebral hemorrhage (ICH) despite adjustment for expected predictors of ICH mortality. Physicians should carefully consider the effect of early limitations in aggressive care to avoid limiting care for patients who may survive their acute illness.

Presentation of intracerebral haemorrhage in a community.

BACKGROUND: Studies on intracerebral haemorrhage (ICH) from tertiary care centres may not be an accurate representation of the true spectrum of disease presentation. OBJECTIVE: To describe the clinical and imaging presentation of ICH in a community devoid of the referral bias of an academic medical centre; and to investigate factors associated with lower Glasgow coma scale (GCS) score at presentation, as GCS is crucial to early clinical decision making. METHODS: The study formed part of the BASIC project (Brain Attack Surveillance in Corpus Christi), a population based stroke surveillance study in a bi-ethnic Texas community. Cases of first non-traumatic ICH were identified from years 2000 to 2003, using active and passive surveillance. Clinical data were collected from medical records by trained abstractors, and all computed tomography (CT) scans were reviewed by a study physician. Multivariable linear regression was used to identify clinical and CT predictors of a lower GCS score. RESULTS: 260 cases of non-traumatic ICH were identified. Median ICH volume was 11 ml (interquartile range 3 to 36) with hydrocephalus noted in 45%. Median initial GCS score was 12.5 (7 to 15). Hydrocephalus score (p = 0.0014), ambient cistern effacement (p = 0.0002), ICH volume (p = 0.014), and female sex (p = 0.024) were independently associated with lower GCS score at presentation, adjusting for other variables. CONCLUSIONS: ICH has a wide range of severity at presentation. Hydrocephalus is a potentially reversible cause of a lower GCS score. Since early withdrawal of care decisions are often based on initial GCS, recognition of the important influence of hydrocephalus on GCS is warranted before withdrawal of care decisions are made.

Differences in intracerebral hemorrhage between Mexican Americans and non-Hispanic whites.

BACKGROUND: Mexican Americans (MAs) have higher incidence rates of intracerebral hemorrhage (ICH) than non-Hispanic whites (NHWs). The authors present clinical and imaging characteristics of ICH in MAs and NHWs in a population-based study. METHODS: This work is part of the Brain Attack Surveillance in Corpus Christi (BASIC) project. Cases of nontraumatic ICH were identified from 2000 to 2003. Multivariable logistic regression was used to assess the independent associations between ethnicity and ICH location (lobar vs nonlobar) and volume (> or = 30 vs < 30 mL), adjusting for demographics and baseline clinical characteristics. Logistic regression was also used to determine the association between ethnicity and in-hospital mortality, adjusting for confounders. RESULTS: A total of 149 MAs and 111 NHWs with ICH were identified. MAs were younger (70 vs 77, p < 0.001), more often male (55% vs 42%, p = 0.04), had a lower prevalence of atrial fibrillation (2.0% vs 13%, p < 0.001), and a higher prevalence of diabetes (39% vs 19%, p < 0.001). MA ethnicity was independently associated with nonlobar hemorrhage (OR 2.08, 95% CI: 1.15, 3.70). MAs had over two times the odds of having small (< 30 mL) hemorrhages compared with NHWs (OR = 2.41, 95% CI: 1.31, 4.46). NHWs had higher in-hospital mortality, though this association was no longer significant after adjustment for ICH volume, location, age, and sex. CONCLUSIONS: There are significant differences in the characteristics of ICH in MAs and NHWs, with MA patients more likely to have smaller, nonlobar hemorrhages. These differences may be used to examine the underlying pathophysiology of ICH.

A population-based study of acute stroke and TIA diagnosis.

BACKGROUND: Acute stroke therapy is heavily dependent on the diagnostic acumen of the physician in the emergency department (ED). OBJECTIVE: To determine this diagnostic accuracy in a population-based multiethnic stroke study. METHODS: The Brain Attack Surveillance in Corpus Christi (BASIC) Project prospectively ascertained all acute stroke or TIA cases in an urban Texas county of 313,645 residents without an academic medical center. Cases were validated by board-certified neurologists using source documentation. Case validation was used as the gold standard to compare the diagnosis given by the ED physician. RESULTS: From January 2000 to August 2002, a total of 13,015 patients were screened. Of these, 1,800 were validated as stroke/TIA. Overall sensitivity of the emergency physician for the BASIC-validated diagnosis was 92%, and positive predictive value was 89%. Of the cases that the emergency physician thought were stroke, 11% were validated as no stroke. In multivariable modeling, motor symptoms was an independent predictor of protection from false-negative ED diagnosis of stroke/TIA (odds ratio [OR] = 0.61; 95% CI 0.41 to 0.89). Protection from false-positive stroke/TIA diagnosis was predicted by sensory symptoms (OR = 0.43; 95% CI 0.28 to 0.66), motor symptoms (OR = 0.44; 95% CI 0.32 to 0.62), and severe neurologic deficit (OR = 0.33; 95% CI 0.14 to 0.78). History of stroke/TIA predicted false-positive stroke diagnosis (OR = 1.72; 95% CI 1.23 to 2.40). The majority of disagreements occurred in patients with generalized neurologic or acute medical, nonneurologic syndromes. CONCLUSIONS: Physicians practicing in the ED are sensitive for stroke/TIA diagnosis. The modest positive predictive value argues for a systems approach with neurology support so that proper decisions regarding acute stroke therapy can be made.