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Updated 6:30 PM June 5, 2007




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A self-fulfilling prophecy? Study examines treatment of intracerebral hemorrhage

Each year tens of thousands of people receive the diagnosis of an intracerebral hemorrhage (ICH) or 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.

There is no approved specific medical treatment for it—although 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.

A new study from the U-M Stroke Program suggests the way the 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 published in the journal Neurology reports that ICH patients who had a do-not-resuscitate (DNR) order issued in the first 24 hours after their stroke, or had care withdrawn or withheld in that time, were twice as likely to die as other ICH patients.

The difference in likelihood of death was independent of other factors typically used to predict ICH death risk, including coma score, age, gender and 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 patient 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 DNR 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 Dr. Darin Zahuranec, a stroke fellow and clinical lecturer at the Medical School.

"Our goal should be to develop therapies that will lead to survival with good outcome rather than survival with severe disability," says senior author Dr. Lewis Morgenstern, 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 was 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.

The new results showed that early limitations on patients' care were associated with both an increased risk of death in the first 30 days after an ICH, and in a longer follow-up period up to several years.

In all, 34 percent of the patients had some sort of limitation placed on their care in the first 24 hours. Another 11 percent of patients had care limitations placed after the first 24 hours. The rest had no limitations.

Altogether, 43 percent of all the patients had died by the end of the first month, and 55 percent by the end of the study period.

Those with care limitations in the first 24 hours were twice as likely to die in the first 30 days and in the entire follow up period as those who had not. They were also more than four times as likely to die in the hospital. And even when the researchers adjusted the data for those who had come to the hospital from a nursing home, the results did not change.

Until ICH scoring tools can be adjusted, "this suggests that physicians should be more humble about our ability to predict an ICH patient's prognosis, particularly in the first day," Zahuranec says.

In addition to Zahuranec and Morgenstern, the study team includes Dr. Devin Brown, Lynda Lisabeth and Melinda Smith of U-M, Dr. N.R. Gonzales of the University of Texas Medical School at Houston, and Dr. P.J. Longwell, a neurologist in Corpus Christi, TX.

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