Which factors influence decisions to transfer and treat patients with acute intracerebral haemorrhage and which are associated with prognosis? A retrospective cohort study

Abstract

ObjectivesTo identify factors associated with the decision to transfer and/or operate on patients with intracerebral haemorrhage (ICH) at a UK regional neurosurgical centre and test whether these decisions were associated with patient survival.DesignRetrospective cohort study.Setting14 acute and specialist hospitals served by the neurosurgical unit at Salford Royal NHS Foundation Trust, Salford, UK.ParticipantsAll patients referred acutely to neurosurgery from January 2008 to October 2010.Outcome measuresPrimary outcome was survival and secondary outcomes were transfer to the neurosurgical centre and acute neurosurgery.ResultsWe obtained clinical data from 1364 consecutive spontaneous patients with ICH and 1175 cases were included in the final analysis. 140 (12%) patients were transferred and 75 (6%) had surgery. In a multifactorial analysis, the decision to transfer was more likely with younger age, women, brainstem and cerebellar location and larger haematomas. Risk of death in the following year was higher with advancing age, lower Glasgow Coma Scale, larger haematomas, brainstem ICH and intraventricular haemorrhage. The transferred patients had a lower risk of death relative to those remaining at the referring centre whether they had surgery (HR 0.46, 95% CI 0.32 to 0.67) or not (HR 0.41, 95% CI 0.22 to 0.73). Acute management decisions were included in the regression model for the 227 patients under either stroke medicine or neurosurgery at the neurosurgical centre and early do-not-resuscitate orders accounted for much of the observed difference, independently associated with an increased risk of death (HR 4.8, 95% CI 2.7 to 8.6).ConclusionsThe clear association between transfer to a specialist centre and survival, independent of established prognostic factors, suggests aggressive supportive care at a specialist centre may improve survival in ICH and warrants further investigation in prospective studies.

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

“…A previous UK study found that patients admitted to neurosurgery tended to have larger hematomas, but were younger with better premorbid health. 13 Exclusion of such patients may introduce ascertainment bias. However, given that ICH accounts for over 10% of our stroke population we believe that the great majority of ICHs presenting to hospital have been captured in SSNAP.…”

No sex differences in long-term functional outcome after intracerebral hemorrhage

“…We confirmed previous studies suggesting men suffered more often from deep ICH 12 and women were on average older than men. 13 As both age and IVH are established parameters affecting outcome, 14 it is notable that a careful statistical approach accounting for these prognostic factors has not been undertaken in previous observational studies. 3,4 When analyzing outcome, it is important to control for do not treat orders.…”

Advances in pre-hospital care - operational experiences from the Melbourne mobile stroke unit

“…Even if patients did not receive surgical intervention, high risk cases require management at a neurosurgical center for neuro-critical care monitoring, especially subarachnoid and subdural hemorrhage. There is also evidence to suggest that hemorrhage cases have better outcomes at neurosurgical centers, regardless of whether surgery was performed [34] .…”