Care-limiting decisions in acute stroke and association with survival: analyses of UK national quality register data

Parry‐Jones, Adrian; Paley, Lizz; Bray, Benjamin; Hoffman, Alex; James, Martin; Cloud, Geoffrey; Tyrrell, Pippa; Rudd, Anthony

doi:10.1177/1747493015620806

Cited by 46 publications

(29 citation statements)

References 13 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…As it is often difficult to reliably predict the outcome of patients at the time they present with ICH, and evidence indicates that the premature use of ‘do-not-resuscitate’ or ‘withdrawal of care’ orders independently predicts mortality,9 10 initiation of an active management plan is recommended unless there are particular clinical (eg, massive ICH with deep coma), comorbid (eg, advanced dementia or malignancy) or social (eg, advanced directives) circumstances. This also allows time for a patient's condition to stabilise, potential complicating factors (eg, seizures and dehydration) to resolve and for counselling family members in the context of their cultural, religious and personal beliefs.…”

Section: Organisation Of Carementioning

confidence: 99%

Medical management of intracerebral haemorrhage

Schreuder¹,

Sato

Klijn³

et al. 2016

J Neurol Neurosurg Psychiatry

View full text Add to dashboard Cite

The global burden of intracerebral haemorrhage (ICH) is enormous. Developing evidence-based management strategies for ICH has been hampered by its diverse aetiology, high case fatality and variable cooperative organisation of medical and surgical care. Progress is being made through the conduct of collaborative multicentre studies with the large sample sizes necessary to evaluate therapies with realistically modest treatment effects. This narrative review describes the major consequences of ICH and provides evidence-based recommendations to support decision-making in medical management.

show abstract

Section: Organisation Of Carementioning

confidence: 99%

Medical management of intracerebral haemorrhage

Schreuder¹,

Sato

Klijn³

et al. 2016

J Neurol Neurosurg Psychiatry

View full text Add to dashboard Cite

show abstract

“…We hypothesize that there was an important left censoring in our study (i.e. patients having undergone life support limitation before ICU admission) that might have mitigated the effect of age and comorbidities [44,45].…”

Section: Discussionmentioning

confidence: 99%

Withholding and Withdrawal of Life Support in Mechanically Ventilated Stroke Patients

Montmollin

Schwebel

Dupuis

et al. 2020

Preprint

View full text Add to dashboard Cite

Background. The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been poorly investigated.Methods. In a prospective multicenter observational cohort (2005-2016), we evaluated limitation of life support in ventilated stroke patients compared to a non-brain-injured population and identified factors associated with such decisions in stroke patients using Fine and Gray competing risk models.Results. We identified 373 stroke patients (ischemic, n=167 (45%); hemorrhagic, n=206 (55%)), and 5683 non-brain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs. non-brain-injured patients, sHR 3.59 [95% CI 2.78-4.65]) and in 33% of hemorrhagic stroke cases (vs. non-brain-injured patients, sHR 3.9 [95% CI 2.97-5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3 - 9] vs 2 [1 - 6] days, p<0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p<0.01). Life support limitation in ischemic stroke was associated with a vertebrobasilar location (vs. anterior circulation, sHR, 1.61 [95% CI 1.01 - 2.59]) and in hemorrhagic stroke, it was associated with an age>70 years (2.29 [1.43 - 3.69]), a Glasgow score<8 (2.15 [1.08 - 4.3]) and a lower non-neurologic admission SOFA score (per point, 0.89 [0.82 - 0.97]).Conclusions. In ventilated stroke patients, decisions to limit life support are more than 3 times more frequent than in non-brain injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.

show abstract

“…1 Survival after ICH differs from ischaemic stroke with a much higher early case fatality in ICH (34% at 1 month versus 12% for ischaemic stroke in a recent UK study 2 ). Despite only causing 1 in 10 strokes, this high case fatality combined with a higher incidence in Asia results in ICH being responsible for a similar proportion of all global deaths as ischaemic stroke (5.8% versus 6.0%, respectively 3 ).…”

Section: Introductionmentioning

confidence: 99%

Hyperacute management of intracerebral haemorrhage

Paroutoglou

Parry‐Jones

2018

Clinical Medicine

Self Cite

View full text Add to dashboard Cite

s9-s12 STROKE on the day of admission than ischaemic strokes (odds ratio: 7.27, 95% CI: 6.31-8.37, p<0.001).2 However, there has been a growing interest in ICH in the stroke research community and findings from recent studies suggest that a more active approach to this patient group is now warranted. We will focus this review on evidence for key interventions in the hyperacute phase of ICH management, that is, the first 24 hours after symptom onset. Early neurological deteriorationIn ICH, a key pathophysiological difference from ischaemic stroke is the presence within the fixed volume of the cranium of a space-occupying lesion, initially composed of the haematoma and subsequently, an increasing volume of vasogenic oedema. 4Should the reserve of space within the cranium be exhausted (Monro-Kellie doctrine), intracranial pressure will begin to rise and fatal brain herniation syndromes may then occur. Baseline haematoma volume is an important predictor of survival and functional outcomes but subsequent early complications that increase intracranial pressure can cause early neurological deterioration in up to half of patients, depending on how it is defined and study duration. 5,6 Haematoma expansion (Fig 1 ) is a principal cause of deterioration in the first 24 hours after onset, with studies indicating that up to 30% of patients demonstrate significant haematoma expansion within hours of onset, which worsens prognosis. 7 Obstructive hydrocephalus may occur with occlusion of cerebrospinal fluid flow, either by occlusion of the ventricular system by intraventricular haemorrhage or extrinsic compression, especially at the third and fourth ventricles. Finally, for larger haematomas in the subacute phase, the addition of Intracerebral haemorrhage causes 1 in 10 strokes, but has the worst overall outcomes of all stroke subtypes. Baseline haematoma volume is a key prognostic factor and early complications -such as haematoma expansion, obstructive hydrocephalus and perihaematomal oedema -may worsen outcome. There is evidence that withdrawal of care may occur more often in intracerebral haemorrhage than ischaemic stroke independent of premorbid health and stroke severity. However, recent evidence shows that reversal of anticoagulants, intensive blood pressure lowering and surgery in carefully selected cases may improve outcomes. Ongoing research may also provide evidence for new medical treatments and minimally invasive approaches to surgery. Effective implementation of evidence-based care to intracerebral haemorrhage patients can be diffi cult but quality improvement methodology can help to achieve maximal benefi t.

show abstract

Care-limiting decisions in acute stroke and association with survival: analyses of UK national quality register data

Abstract: When compared to ischemic stroke, patients with ICH are much more likely to commence palliative care during the first 72 h of their care, independent of level of consciousness, age, and premorbid health.

Cited by 46 publications

References 13 publications

Medical management of intracerebral haemorrhage

Medical management of intracerebral haemorrhage

Withholding and Withdrawal of Life Support in Mechanically Ventilated Stroke Patients

Hyperacute management of intracerebral haemorrhage

Contact Info

Product

Resources

About