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Researchers find similar case-fatality rates among patients with intracerebral hemorrhage in 1988, 2005; more trials warranted to improve ICH outcomes

Tuesday, December 16 2008 | Comments
Evidence Grade 0 What's This?
The frequency of surgery for intracerebral hemorrhage (ICH) was lower in 2005 than in 1988, according to a recently published study, but the overall ICH case-fatality rate was not improved in 2005 compared with 1988, suggesting the need for innovative therapies and clinical trials in the care of ICH.

The study investigators said the decreased use of surgery to treat ICH could reflect the impact of recent clinical trial data that demonstrate no clear benefit to surgery relative to medical management in this setting.

In their investigation, the University of Cincinnati researchers identified all residents aged >=18 years from the greater Cincinnati and northern Kentucky area who were hospitalized with spontaneous ICH in 1988 and 2005. Patient demographics and clinical information were obtained from medical chart reviews, and ICH location was determined from available imaging. Illness severity was measured by Glasgow Coma Scale scores, which were recorded at hospital admission. ICH volume was determined by computerized image analysis in 1988 and by the abc/2 method in 2005. The researchers also calculated rates and timing of surgery, along with the case-fatality rate. Comparisons were made between the 1988 and 2005 groups for each of these measurements.

After excluding certain cases, the 1988 group included 171 patients (67 lobar, 80 deep cerebral, 10 brainstem, and 14 cerebellar) and the 2005 group included 259 patients (91 lobar, 123 deep cerebral, 19 brainstem, and 26 cerebellar).

There were no significant differences in age or sex between the 2 groups. However, there was a higher proportion of white patients in the 1988 group (P=.03). Glasgow Coma Scale scores at admission, ICH location, hemorrhage volumes, and the timing of surgery were similar between the 2 groups.

Sixteen percent of the patients underwent surgical removal of their ICH in 1988, compared with 7% in 2005 who did so (P=.002). Among those with cerebellar hemorrhage, 36% underwent surgery in 1988 versus 27% in 2005 (P=.56). In both time periods, the patients treated surgically were younger than those treated nonsurgically (P=.02).

In 1988, the 30-day case-fatality rate was 32% among the patients who underwent surgery and 50% among those who did not (P=.06); in 2005, the respective rates were 16% and 45% (P=.02).

Overall, the 30-day case-fatality rates for the patients with lobar and deep cerebral ICH were comparable in 1988 and 2005 (46% vs 42%, respectively; P=.80).

"In summary, the lower frequency of surgery in 2005 compared with 1988 may reflect the impact of trials that suggest no clear benefit to surgery after ICH and/or data indicating the poor outcome of patients with very large hemorrhages at presentation," the authors concluded. "Given similar ICH case-fatality rates in 1988 and 2005, innovative clinical trials to improve ICH patient outcomes are warranted." (Adeoye O, et al. Neurosurg 2008;63:1113-1118.)

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