Stroke unit admission is associated with better outcome and lower mortality in patients with intracerebral hemorrhage

Abstract

Background and purpose There is no clear consensus among current guidelines on the preferred admission ward [i.e. intensive care unit (ICU) or stroke unit (SU)] for patients with intracerebral hemorrhage. Based on expert opinion, the American Heart Association and European Stroke Organization recommend treatment in neurological/neuroscience ICUs (NICUs) or SUs. The European Stroke Organization guideline states that there are no studies available directly comparing outcomes between ICUs and SUs. Methods We performed an observational study comparing outcomes of 10 811 consecutive non‐comatose patients with intracerebral hemorrhage according to admission ward [ICUs, SUs and normal wards (NWs)]. Primary outcomes were the modified Rankin Scale score at discharge and intrahospital mortality. An additional analysis compared NICUs with SUs. Results Treatment outside an SU was associated with higher odds for an unfavorable outcome [ICU vs. SU: odds ratio (OR), 1.27; 95% confidence interval (CI), 1.09–1.46; NW vs. SU: OR, 1.28; 95% CI, 1.08–1.52] and higher odds for intrahospital mortality (ICU vs. SU: OR, 2.11; 95% CI, 1.75–2.55; NW vs. SU: OR, 1.52; 95% CI, 1.23–1.89). A subgroup analysis of severely affected patients treated in dedicated NICUs (vs. SUs) showed that they had a lower risk of a poor outcome (OR, 0.45; 95% CI, 0.26–0.79). Conclusions Treatment in SUs was associated with better functional outcome and reduced mortality compared with ICUs and NWs. Our findings support the current guideline recommendations to treat patients with intracerebral hemorrhage in SUs or NICUs and suggest that some patients may further benefit from NICU treatment.

2022 Guideline for the Management of Patients With Spontaneous Intracerebral Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

“…A prospective observational study of 10 811 consecutive patients with spontaneous ICH who were not comatose and did not require mechanical ventilation in the first 24 hours from admission found that treatment in a stroke unit was associated with improved functional outcomes compared with treatment in either an ICU (OR, 1.27 [95% CI, 1.09–1.46]) or a general ward and that mortality was higher in an ICU (OR, 2.11 [95% CI, 1.75–2.55]) or a general ward compared with a stroke unit. 237 In a subgroup analysis of severely affected patients (NIHSS score 10–25), adjusted mortality was not different when stroke units were compared with neurointensive care units, although the odds of a poor outcome (mRS score >3) was significantly lower for patients treated in a neurointensive care unit (OR, 0.45 [95% CI, 0.26–0.79]). Other nonrandomized prospective studies that included patients with ICH have reported reduced fatality and improved outcomes, especially at longer-term follow-up.…”

Quantifying regional variations in components of acute stroke unit (ASU) care in the international HeadPoST study

“…National guidelines universally recommend well-organised, interdisciplinary, acute stroke unit (ASU) care [1][2][3][4], based upon consistent evidence from systematic reviews and individual trials showing improved survival and functional recovery [5,6], with the treatment effect being consistent across a range of patient characteristics within all age groups and different stroke subtypes [7][8][9][10]. However, such care is absence or only partially established in many hospitals around world [11].…”

Canadian stroke best practice recommendations: Management of Spontaneous Intracerebral Hemorrhage, 7th Edition Update 2020

“…Patients with ICH treated on a specialized stroke unit have been shown to have reduced risks of death or dependency (RR ¼ 0.81, 95% CI 0.71-0.92, p < 0.0001), 39 decreased in-hospital mortality (OR ¼ 3.4; 95% CI 1.65-7.6), 40,41 and improved short and long-term survival 42 compared with care on nonspecialized units.…”

“…While it is now well-accepted that patients with ischemic stroke admitted to a stroke unit featuring dedicated beds and staff have better outcomes compared with patients admitted to general or less-specialized units, there is also evidence that the subset of patients who have experienced ICH realize the same benefits. Patients with ICH treated on a specialized stroke unit have been shown to have reduced risks of death or dependency (RR = 0.81, 95% CI 0.71–0.92, p < 0.0001), 39 decreased in-hospital mortality (OR = 3.4; 95% CI 1.65–7.6), 40,41 and improved short and long-term survival 42 compared with care on nonspecialized units.…”