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Optimism for Long-Term Recovery in Survivors of ICH, IVH

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A new study suggests a brighter future for survivors of severe intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH), which initially seemed unfavorable in the long term.

The investigators analyzed functional outcome trajectories in more than 700 ICH or IVH survivors who had very poor functional outcomes at day 30 post-event.

More than 40% of these patients achieved favorable outcomes within 1 year, with one third being functionally independent. Moreover, by the age of 1, almost two-thirds returned home, and quality of life indicators showed a significant increase in all subjects.

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The inclusion of hospital events, pre-existing conditions, and responses to therapy in predictive models has improved the prediction of future recovery.

“The main takeaway from this study is that the approach to many patients with ICH needs to change,” Senior Author Wendy Ziai, MD, MPH, Medical Director of the Neurovascular Laboratory and Professor of Neurology at Johns Hopkins Hospital, Baltimore, Maryland. , Medscape Medical News reported.

“Our data support longer evaluation periods for patients with ICH with follow-up for in-hospital events and response to therapy to provide a better understanding of long-term recovery,” she said.

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The study was published online July 25 in the journal JAMA Neurology.

Self-fulfilling prophecy?

The authors note that ICH prediction is historically performed on admission and most models predict short-term outcomes. Most studies also do not describe long-term recovery among those with initial severe disability.

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Most predictive models include baseline factors for ICH severity but do not take into account comorbidities, hospital interventions, and complications, whereas IVH scoring scales typically only include baseline IVH volume, not IVH expansion, volume depletion, or hydrocephalus, which “may also influence recovery” . .”

“Most ICH patients who die in the hospital die after the decision to withdraw life-sustaining measures is made due to what medical professionals perceive as a high likelihood of poor long-term outcomes,” Ziai noted.

“These decisions can lead to a self-fulfilling prophecy of a bad outcome,” she continued. “Even a ban on resuscitation is associated with an increased risk of mortality and may reduce the likelihood of a favorable functional outcome if applied early.”

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To assess outcome trajectories up to 1 year after ICH, investigators performed a longitudinal retrospective analysis of all 500 patients with spontaneous obstructive IVH randomized to receive intraventricular alteplase or placebo in the CLEAR-III study and 499 patients with spontaneous large supratentorial ICH without obstructive IVH at random. scheduled for stereotactic thrombolysis or standard care in the MISTIE study.

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Both studies were neutral for the primary endpoint of improved functional outcome, but found a significant reduction in mortality in the active treatment groups at 180 days and 1 year, respectively.

The final pooled group included 715 patients who survived to day 30 with a Modified Rankin Scale (mRS) score of 4 (29.5%) or 5 (69.5%). Their median age was 60.3, 58% male, 68.6% white, 24.3% black, and 13.7% Hispanic.

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Baseline characteristics included age, gender, race, ethnicity, stroke-related comorbidities, Glasgow Coma Scale and National Institutes of Health Stroke Scale (NIHSS) scores, and hematoma volumes (measured at admission, when ICH and IVH were stable, at at the end of treatment and 30 days after inclusion in both trials).

The primary outcome measure was 1-year mRS with assessments performed in both trials at days 30, 180, and 365.

Patients were divided into two groups depending on the annual outcome: “good” (mRS 0-3) and “poor” (mRS 4-6).

Secondary outcomes were 1-year mortality, discontinuation of life-sustaining treatment, home discharge, and European Visual Analogue Quality of Life score.

Avoid early termination of life-sustaining therapy

By year 1, 18% of participants had died, 43% had achieved an mRS score of 0 to 3, and 64.6% of survivors returned home a median of 98 (52–302) days after the attack.

Among 308 patients who recovered by 1 year with a good outcome, 95.4% returned home. Moreover, 41% of patients who had a persistent adverse outcome after 1 year were also able to return home.

In adjusted models for the combined cohort, factors in the table below at day 30 were associated with no recovery.

Factor aOR (95% CI)
Diabetes 0.50 (0.26 – 0.96)
NIHSS 0.93 (0.90 – 0.96)
Severe leukoaraiosis 0.30 (0.16 – 0.54)
Displacement of the pineal gland 0.87 (0.76 – 0.99)
Acute ischemic stroke 0.44 (0.21 – 0.94)
gastrostomy 0.30 (0.17 – 0.50)
Persistent hydrocephalus 0.37 (0.14 – 0.98)

On the other hand, ICH resolution (adjusted odds ratio [aOR]. 1.82; 95% CI, 1.08–3.04) and IVH (aOR, 2.19; 95% CI, 1.02–4.68) by day 30 were associated with recovery to a good outcome.

Additional factors associated with poor outcome included cerebral perfusion pressure less than 60 mm, sepsis, prolonged mechanical ventilation, and the need to monitor intracranial pressure.

Thirty-day event-based models “strongly predicted” 1-year outcome (AUC, 0.87; 95% CI, 0.83–0.90) with “significantly improved discrimination” compared to models using only baseline severity factors (AUC, 0.76; 95% CI). , 0.71 – 0.80), the authors report.

“While there are still no proven interventions for ICH patients that definitively improve outcomes, the effective reduction in hematoma volume, as studied in these clinical trials, was significantly associated with an improved ability to distinguish between patients who ultimately experienced functional recovery. after 1 year, and those who didn’t,” commented Ziay.

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The findings “highlight the importance of promoting aggressive treatment and avoiding early withdrawal of life-sustaining therapy in the acute phase after ICH,” she said.

Practice-Changing Consequences

Commenting for Medscape Medical News, Magdi Selim, MD, professor of neurology at Beth Israel Deaconess Medical Center in Boston, Massachusetts, said the study results have “practice-changing implications.”

Recovery from ICH is “slow, but many patients can recover with active care and time,” said Selim, author of the accompanying editorial.

Patients and their families “should be informed that the effects of aggressive measures may not be noticeable in the short term and that ICH patients require patience from their providers and caregivers,” said Selim, who was not involved in the study.

He noted that the majority of deaths after ICH occur as a result of early discontinuation of treatment “due to perceived long-term poor outcome by treating physicians and family.” The results of the study “clearly indicate that clinicians and family members should exercise caution before limiting aggressive care early on to maximize patients’ chances of recovery.”

Ziai reported grants from the National Institutes of Health during the study, personal honoraria from CR Bard DMC, and work as an assistant editor for Neurocritical Care outside of submitted work. Disclosures by other authors are listed in the original article. Selim reported on grants from the National Institute of Neurological Disorders and Stroke and the National Institute on Aging; royalties from UpToDate and Cambridge University Press; and serving on the advisory board of MedRhythms Inc.

JAMA Neurol. Posted online July 25, 2022 Editorial abstract

Dad Swift Yasgur, Massachusetts, LSW, is a freelance writer with a consulting practice in Teaneck, New Jersey. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-focused health books, as well as Behind the Burqa: Our Life in Afghanistan and How We Fled to Freedom.

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