The outcome after out-of-hospital cardiac arrest has historically been grim at best. The current overall survival rate of patients admitted to a hospital is approximately 10%, making cardiac arrest one of the leading causes of death in the United States. The situation is improving with the incorporation of therapeutic temperature modulation, aggressive prevention of secondary brain injury, and improved access to advanced cardiovascular support, all of which have decreased mortality and allowed for better outcomes. Mortality after cardiac arrest is often the direct result of active withdrawal of life-sustaining therapy based on the perception that neurological recovery is not possible. This reality highlights the importance of providing accurate estimates of neurological prognosis to decision makers when discussing goals of care. The current standard of care for assessing neurological status in patients with hypoxic-ischemic encephalopathy emphasizes a multimodal approach that includes five elements: (1) neurological examination off sedation, (2) continuous electroencephalography, (3) serum neuron-specific enolase levels, (4) magnetic resonance brain imaging, and (5) somatosensory-evoked potential testing. Sophisticated decision support systems that can integrate these clinical, imaging, and biomarker and neurophysiologic data and translate it into meaningful projections of neurological outcome are urgently needed.

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Introduction: Intracerebral hemorrhage (ICH) is a devastating form of stroke that is usually related to chronic hypertension. End stage renal disease (ESRD) requiring renal replacement therapy (RRT) often leads to chronic hypotension, and fluid shifts during dialysis might increase the severity of brain edema. We sought to better understand the impact of ESRD on outcomes after ICH, with a focus of the presence of hypertension or hypotension during hospitalization. Methods: We analyzed the National Inpatient Sample (NIS) database and extracted all cases of ICH (ICD-9 431 or ICD-10 I61) between 2012 and 2017. Patients were classified as requiring RRT (ICD9: V56, V4511, 5856; ICD 10: N186, Z49, Z992) or not. We also noted the presence of codes for hypertension, hypotension, or cerebral herniation. The main outcome measure was death at discharge. Logistic regression was used to calculate odds ratios for mortality with adjustment for ICH severity using a compilation of codes for common complications. Results: 116,812 ICH patients were identified, 3,329 (2.8%) of whom received RRT. Mortality in the non-RRT group was 18% as opposed to 32% in the RRT group (severity adjusted odds ratio 2.1, 95% CI 2.0–2.3, P<0.001). Hypertension was common (67%) and hypotension uncommon (1.7%) in the non-RRT group. Hypotension was associated with much higher mortality (32%) than patients who were hypertensive (18%) or normotensive (23%) in non-RRT patients. By contrast, hypertension in the RRT group occurred much less frequently (21%) and hypotension was slightly more common in the RRT group (2.1%). There was no significant relationship between extremes of blood pressure and mortality in the RRT group. Compared to normotensive patients, herniation occurred more frequently in hypotensive non-RRT patients (28% vs 14%, OR 1.5, 95% CI 1.5–1.7, P<0.001). No relationship between BP and herniation was identified in patients with ESRD. Conclusion: ESRD requiring RRT is associated with a 78% relative increase in mortality after ICH. Whereas hypotension increases the risk of death in ICH patients with preserved renal function, hypotension is much more common in ESRD patients and does not confer the same hazard. Further research is needed to understand how ESRD increases mortality after ICH.

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