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that ICH patients who had a do-not-resuscitate order issued in the first 24 hours after their stroke, or had care withdrawn or withheld in that time, were twice as likely to die as other ICH patients.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