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- Prediction of short-term prognosis in elderly patients with spontaneous intracerebral hemorrhagePublication . Batista, António; Osório, Rui; Varela, Ana; Guilherme, Patrícia; Marreiros, Ana; Pais, Sandra; Nzwalo, HipólitoAim The incidence of spontaneous intracerebral hemorrhage (SICH) increases with age. Data on SICH mortality in the very old are sparse. We aimed to describe the predictors of 30-day SICH mortality in the very elderly in southern Portugal. Methods A total of 256 community representative SICH patients aged >= 75 years (2009-2016) were included. Multiple logistic regression was used to identify predictors of 30-day mortality. Results Mean age was 82.1 years; 57.4% males. The 30-day case fatality was 38.7%. The frequency of patients taking anticoagulants (29.3% vs. 11.5%); comatose (46.9% vs. 2.5%); with hematoma volume >= 30 mL (64.6% vs. 13.4%); intraventricular dissection (78.8% vs. 27.4%) was higher in deceased patients (p < 0.05). Survivors were more often admitted to stroke unit (SU) (68.2 vs. 31.3%) and had lower mean admission glycaemia values (p < 0.05). The likelihood of death was increased in patients with higher admission hematoma volume (>= 30 mL) (OR: 8.817, CI 1.753-44.340, p = 0.008) and with prior to SICH history of >= 2 hospitalizations OR = 1.022, CI 1.009-1.069, p = 0.031). Having higher Glasgow coma scale score, OR: 0.522, CI 0.394-0.692, p < 0.001, per unit was associated with reduced risk of death. Age was not an independent risk factor of short-term death. Conclusions The short-term mortality is high in very elderly SICH. Prior to SICH history of hospitalization, an indirect and gross marker of coexistent functional reserve, not age per se, increases the risk of short-term death. Other predictors of short-term death are potentially manageable reinforcing the message against any defeatist attitude toward elderly patients with SICH. Key summary pointsAim Identification of predictors of short-term death after spontaneous intracerebral hemorrhage (SICH) in the elderly. Findings The short-term case fatality (38.7%) after SICH is high in the elderly. Hematoma volume, decreased level of consciousness and functional reserve, but not age per se, increase the risk of short-term death. Message Age per se should not justify any decision of withholding best treatment in elderly SICH patients. Offering the best acute treatment can potentially improve the clinical outcome.
- Impact of process of care in the short-term mortality in non-severe intracerebral hemorrhage in southern PortugalPublication . Fernandes, Adriana; Taveira, Isabel; Soares, Rita; Marreiros, Ana; Nzwalo, HipólitoIntroduction: Patients with spontaneous intracerebral hemorrhage (SICH) face the worse functional and vital prognosis among all stroke subtypes. In cases of severe SICH, therapeutic inertia or nihilism complicates meaningful identification of outcome predictors. Therefore, we sought to investigate clinic-radiological and process of care predictors of short-term mortality in patients with mild to moderate SICH. Patients and methods: Observational retrospective community representative consecutive case series of patients from Algarve, southern Portugal. Logistic regression was used to identify predictors of short-term (30-day) death. Results: Mortality was 23.9% (111/464). Most important predictors of death were unconsciousness at admission (OR = 12.392, 95% CI = 3.816-40.241, p < 0.001), hospital arrival > 6 h after stroke onset (OR = 2.842, 95% CI = 1.380-5.852, p =.005), hematoma volume > 30 cc/cm3 (OR = 3.295, 95% CI 0 1.561-6.953, p =.002), intraventricular extension (OR = 2.885, 95% CI = 1.457-5.712, p =.002) and > 24 h in the Emergency Department (OR =19.675, 95% CI = 3.682-34.125, p =.009). Stroke Unit (SU) admission reduced the likelihood of death (OR = 0.293, 95% CI = 0.137-0.682, p =.002). Conclusion: The observed mortality is high. Apart from the traditional clinic-radiological factors, in mild to moderate SICH, process of care related factors have strong impact on mortality. These results highlight the need of continuous improvement of SICH care to improve the prognosis.
- Incidence and case-fatality from spontaneous intracerebral hemorrhage in a southern region of PortugalPublication . Nzwalo, Hipólito; Nogueira, Jerina; Félix, Catarina; Guilherme, Patrícia; Baptista, Alexandre; Figueiredo, Teresa; Ferreira, Fatima; Marreiros, Ana; Thomassen, Lars; Logallo, NicolaBackground: There is scarce information on incidence and case fatality of spontaneous intracerebral hemorrhage (SICH) in certain regions of the world, including in Europe. There is no community-based data on SICH in Southern Portugal. Aim: To determine the incidence and early case-fatality from SICH in Algarve, the southernmost region of Portugal. Methods: The recommended criteria for stroke incidence studies was used to identify cases of incident first-ever SICH from January 1st to December 31st 2015 in a subregion with 280,081 inhabitants. Crude incidence rates per age group and gender; standardized rates to the European population; and age adjusted case fatality rates were calculated. Results: Eighty-two first-ever cases of SICH (64.6% men) occurred. The mean age was 72.3 years (SD +/- 12.1); women were 3 years older than men on average and had more frequently lobar SICH. The crude annual incidence rate was 29.2/100,000 (95% CI 23.4- 38.6; p < 0.001); higher in men (39.7/100,000) than women (19.8/100,000). The standardized to the European population incidence was 15.1/100,000 (95% CI 3.6-18.9; p < 0.05); 26.9 and 10.9/100,000 for men and women respectively. The 30-day case-fatality was 40 % (95% CI 29-51) and increased steeply with age Conclusion: The incidence of SICH in Southern Portugal was high, but within the figures found in some parts of Europe. However, a marked predominance of males was found and the case-fatality rate was amongst the highest reported in western countries. (C) 2017 Elsevier B.V. All rights reserved.
- Clinical course and outcomes of small supratentorial intracerebral hematomasPublication . Behrouz, Reza; Misra, Vivek; Godoy, Daniel A.; Topel, Christopher H.; Masotti, Luca; Klijn, Catharina J. M.; Smith, Craig J.; Parry-Jones, Adrian R.; Slevin, Mark A.; Silver, Brian; Willey, Joshua Z.; Masjuan Vallejo, Jaime; Nzwalo, Hipólito; Popa-Wagner, Aurel; Malek, Ali R.; Hafeez, Shaheryar; Di Napoli, MarioBackground and Purpose: Intracerebral hemorrhage (ICH) volume, particularly if >= 30 mL, is a major determinant of poor outcome. We used a multinational ICH data registry to study the characteristics, course, and outcomes of supratentorial hematomas with volumes <30 mL. Methods: Basic characteristics, clinical and radiological course, and 30-day outcomes of these patients were recorded. Outcomes were categorized as early neurological deterioration (END), hematoma expansion, Glasgow Outcome Scale (GOS), and in-hospital death. Poor outcome was defined as composite of in-hospital death and severe disability (GOS = 3). Comparison was conducted based on hemorrhage location. Logistic regression using dichotomized outcome scales was applied to determine predictors of poor outcome. Results: Among 375 cases of supratentorial ICH with volumes <30 mL, expansion and END rates were 19.2% and 7.5%, respectively. Hemorrhage growth was independently associated with END (odds ratio: 28.7, 95% confidence interval [CI]: 8.51-96.5; P < .0001). Expansion rates did not differ according to ICH location. Overall, 13.9% (exact binomial 95% CI: 10.5-17.8) died in the hospital and 29.1% (CI: 24.5-34.0) had severe disability at 30 days; there was a cumulative poor outcome rate of 42.9% (CI: 37.9-48.1). Age, admission Glasgow Coma Scale, intraventricular extension, and END were independently associated with poor outcome. There was no difference in poor outcome rates between lobar and deep locations (40.2% versus 43.8%, P = .56). Conclusion: Patients with supratentorial ICH <30 mL have high rates of poor outcome at 30 days, regardless of location. Nearly 1 in 5 hematomas <30 mL expands, leading to END or death.
- Poor intensive stroke care is associated with short-term death after spontaneous intracerebral hemorrhagePublication . Martinez, Joana; Mouzinho, Maria; Teles, Joana; Guilherme, Patricia; Nogueira, Jerina; Felix, Catarina; Ferreira, Fatima; Marreiros, Ana; Nzwalo, HipólitoObjectives: The case fatality from spontaneous ICH (SICH) remains high. The quality and intensity of early treatment is one of the determinants of the outcome. We aimed to study the association of early intensive care, using the Intracerebral Hemorrhage-Specific Intensity of Care Quality Metrics (IHSICQM) with the 30-day in-hospital mortality in Algarve, Portugal. Patients and Methods: analysis of prospective collected data of 157 consecutive SICH patients (2014-2016). Logistic regression was performed to assess the role of IHSICQM on the 30-day in-hospital mortality controlling for the most common clinical and radiological predictors of death. Receiver operating characteristic (ROC) curve was developed to evaluate the prediction accuracy of the IHSICQM score (C-statistics). Results: forty-five (29 %) patients died. The group of deceased patients had lower intensity of care (lower IHSICQM score) and higher proportion of poor prognosis associated factors (pre-ICH functional dependency, intraventricular dissection/glycaemia). On the multivariate analysis, higher IHSICQM was associated with reduction of the odds of death, 0.27 (0.14-0.50) per each increasing point. The ROC curve showed a high discriminating ability of isolated IHSICQM in predicting the 30-day mortality (AUC = 0,95; 95 % CI = [0,86; 0,95]). Conclusion: the early intensity of quality of care independently predicts the 30-day in-hospital mortality. Quantification of the intensity of SICH is a valid tool to persuade improvement of SICH care, as well to help comparison of performances within and between hospitals.
- Fine particulate air pollution and occurrence of spontaneous intracerebral hemorrhage in an area of low air pollutionPublication . Nzwalo, Hipólito; Guilherme, Patricia; Nogueira, Jerina; Felix, Catarina; S. André, Ana; Teles, Joana; Mouzinho, Maria; Ferreira, Fatima; Marreiros, Ana; Logallo, Nicola; Bentes, CarlaObjectives:The association between short-term ambient particulate matter ≤ 2.5 μm diameter (PM2.5) andspontaneous intracerebral hemorrhage (SICH) occurrence is unclear. We aimed to study the association ofambient PM2.5 with occurrence of SICH in an area of low air pollution in southern Portugal.Patientsandmethods:PM2.5 levels from the 3 days before the SICH event (Lag 1, 2, 3) was compared with onecontrol period (Lag 15–17) using a case-crossover analysis. Conditional logistic regression was used to estimatethe odds ratio (OR) with 95% confidence interval (CI). Analysis was stratified by gender, age, functional neu-rological status, type of SICH, environmental factors (temperature, humidity, time of day and season).Results:Three-hundred and eight patients were included (2010–2015); mean age 70.8 years, 62.8% were males.The mean values (μg/l) of PM2.5 were higher on the case days (Lag1 = 7.76, Lag2 = 7.64, Lag3 = 7.74)compared to control period (Lag14-17 = 6.77). For each 10 μg/l increase, the likelihood of SICH increased 5.7%(95% CI = 1.020-1.095. P = .002). The strength of the association was higher in patients younger than 70 years(OR = 1.064, 95% CI = 1.009–1.122); without prior to SICH neurological disability (OR = 1.061, 95% CI1.022–1.101); with non-lobar type (OR = 1.054, 95% CI = 1.012–1.099). A circadian and circannual patternwas present with increased strength of the association when SICH occurred in the morning time (OR = 1,067,95% CI = 1.012–1.125), in the fall (OR = 1.118, 95% CI = 1.031–1.213) and the in the winter (OR = 1.064,95% CI = 1.002–1.129). The association was also potentiated at lower temperature values.Conclusion:Short-term increases of PM2.5 are associated with occurrence of SICH in Algarve, a region of lowambient pollution. Patient and ambient level factors can influence the strength of this association.