A major factor has been overlooked in the way bleeding stroke patients' survival is calculated

May 15 2007

Each year, tens of thousands of people receive a dreaded diagnosis: intracerebral hemorrhage, or a "bleeding stroke."

Caused by a burst blood vessel in the brain, ICH kills a quarter of patients in two days, and up to half of them within 30 days. And there's no approved specific medical treatment for it -- though people can recover with specialized hospital care.

Figuring out which ICH patients might survive if they receive aggressive treatment, and which will die or be severely disabled, challenges doctors every day.

Now, a new study from the University of Michigan Stroke Program suggests that the way those odds are calculated might be skewed.

It also lends credence to the idea that ICH patients might be victims of a "self-fulfilling prophecy": that their odds of survival may be made worse by the withholding of aggressive treatment based on an inaccurate calculation of their chances.

The study finds that ICH patients who had a do-not-resuscitate order issued in the first 24 hours after their stroke, or had care withdrawn or withheld in that time, were twice as likely to die as other ICH patients. It is published in the journal Neurology.

The difference in likelihood of death was independent of other factors typically used to predict ICH death risk, including coma score, age, gender, and the size of the bleeding area. The study involved 270 patients who were treated for ICH at seven community hospitals in Texas over a three-year period.

The fact that early limitations on patients' care were associated with such a large difference in mortality risk surprised the researchers. It's such a large effect that they say it should probably be considered when doctors use risk-calculation tools to predict the chance of death after ICH. Such tools are based on data from groups of past ICH patients, but none of the current tools take into account the level of care the patients received.

If nothing else, the study bolsters recent American Stroke Association guidelines published earlier this month, which recommend that new do-not-resuscitate orders not be issued in the first 24 hours after an ICH, and that patients receive care from an experienced intensive-care team that can provide the best evidence-based care.

"There are situations where a DNR order or withdrawing care is very appropriate for ICH patients, and others where intense supportive care can help even the most critically ill patient survive," says lead author Darin Zahuranec, M.D., a stroke fellow and clinical lecturer at the U-M Medical School. "The challenge is predicting who is whom."

"Our goal should be to develop therapies that will lead to survival with good outcome rather than survival with severe disability," says senior author Lewis Morgenstern, M.D., director of the U-M Stroke Program and of the Texas stroke study that yielded the data used in the analysis.

Called BASIC for Brain Attack Surveillance in Corpus Christi, the study used intensive medical record reviews to assess many aspects of stroke patients' care in the hospital and survival both before and after discharge. Average follow-up time was 417 days.

BASIC is funded by the National Institute of Neurological Disorders and Stroke, part of the National Institutes of Health. The ICH project was also supported by a postdoctoral fellowship grant from the American Heart Association.

The new results showed that early limitations on patients' care were associated with an increased risk of death both in the first 30 days after an ICH, and in a longer follow-up period up to several years.

In all, 34 percent of the patients had some sort of limitation placed on their care in the first 24 hours. They tended to be older and to have higher coma scores than other patients. A few had come to the hospital with a DNR already in place. Another 11 percent of patients had care limitations placed after the first 24 hours were over. The rest had no limitations placed on their care.

In all, 43 percent of all the patients had died by the end of the first month, and 55 percent had died by the end of the study period.

Those who had had care limitations in the first 24 hours (dubbed "early" limitations by the researchers) were twice as likely to die in the first 30 days and in the entire follow up period as those who had not. They were also more than four times as likely to die in the hospital. And even when the researchers adjusted the data for those who had come to the hospital from a nursing home, the results did not change.

Although it's impossible to know what would have happened if all the patients in the study had had no limitations placed on their care, the results show that a major factor has been overlooked in the way ICH patients' survival is calculated.

Until ICH scoring tools can be adjusted, "this suggests that physicians should be more humble about our ability to predict an ICH patient's prognosis, particularly in the first day," says Zahuranec.

In short, families whose loved ones have suffered an ICH should seek to get them to a specialized center as soon as possible. At the same time, they should speak with the patient's doctors about end-of-life options if the aggressive treatment doesn't appear to be improving the patient's outlook after a day or more.