Stroke Unit Touted Most Effective to Treat Hemorrhage

Peter Ringleb, MD

Patients with intracranial hemorrhage (ICH) reported better functional outcome and reduced mortality when admitted into stroke units (SU) compared to intensive care units (ICU) or normal wards (NW).¹ Notably, these findings support the current American Heart Association/American Stroke Association guideline recommendations for treating patients with ICH in SU.²

When assessing functional outcome and mortality, data showed that 6223 patients had an unfavorable outcome, while 14.9% of patients died during treatment in hospital. Patients admitted to an ICU (odds ratio [OR] 1.27 [95% CI; 1.09 — 1.46]) or a NW (OR 1.28 [95% CI; 1.08 – 1.52]) had reported higher adjusted odds for an unfavorable outcome than for admission to a SU.

Intrahospital mortality risk was higher in patients treated in ICUs (OR 2.11 [95%; 1.75 — 2.55]) and in NWs (OR 1.52 [95% CI; 1.23 – 1.89]) than those in SUs. Additionally, the odds for mortality (OR 1.63 [95% CI; 1.29 – 2.07]) were higher in ICUs than in SUs and similar functional outcomes were achieved (OR 1.10 [95% CI; 0.78 – 1.55]).

“Our findings support the recommendations of both the European Stroke Organization (ESO) and American Heart Association (AHA) guidelines that ICH should be treated in SUs or NICUs,” the study authors, including Peter Ringleb MD, professor of vascular neurology, and head, Neurovascular Service, University Hospital Heidelberg, wrote. “The relatively high rate of ICH patients treated in hospitals without a SU or in non-neurological ICUs, together with the limited access to NICUs, may indicate that there is potential for improvement in stroke care.”

The observational study included 10,811 consecutive non-comatose ICH patients (48.2% female; mean age 73.8 +12.8 years) admitted into either a SU, ICU, or NW. Patients excluded from the study suffered ICH as a complication of thrombolysis or endovascular recanalization treatment, as well as those who were transferred to another hospital to rule out double inclusion. Other exclusions include those who needed mechanical ventilation or patients who were comatose.

Upon admission and discharge, investigators documented stroke severity and the elimination of the prestroke modified Rankin Scale (pmRS) scores. Favorable (mRS < 2 or attainment of pmRS) and unfavorable outcome (mRS >2 and >pmRS)(8) were the 2 categories to assess functional outcomes. Additionally, other demographic details such as age, sex, and distribution of patients by ward of admission and age, as well as comorbidities (atrial fibrillation, diabetes, and recurrent stroke) were documented.

Patients with National Institute of Health Stroke Scale (NIHSS) scores between 10 to 25 treated at major centers were included in the subgroup analysis. Hospital level, distribution of patients by admission ward (ICU, SU, and NW), referring medical unit, time to admission and length of hospital stay were also recorded.

Of the 10,811 participants, 64.3% of the patients were admitted to SUs, 15.5% to NWs, and 20.2% to ICUs. At admission, the median pmRS and mRS were 0 (IQR 0-1) and 4 (IQR 3-5).

Investigators also included an additional analysis that compared patient outcomes in severe cases when administered into a neurological/ neuroscience intensive care unit (NICU) or a SU.

REFERENCES

1. Ungerer MN, Ringleb P, Rueter B, et al. Stroke unit admission is associated with better outcome and lower mortality in patients with intracerebral hemorrhage. Eur. J Neurol. Published online February 5, 2020. doi:10.1111/ene.14164.

2. Hemphill JC, Greenberg SM, Anderson CS,, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. Stroke. 2015.46(7):2032-60