Mejores predicciones a largo plazo en sobrevivientes intracerebrales e intraventriculares hemorrhages

The majority of patients with Intracerebral Hemorrhage Women who die in the hospital do so after taking the decision to withdraw vital support measures.

The prediction of the future recovery, thanks to the inclusion of previous hospital events, preexisting conditions, and model therapies. Photo: Shutterstock.

Nuevos y mejores expectations para aquellos sobrevivientes de Intracerebral Hemorrhage Women (HIC) y Intraventricular hemorrhage (HIV) que initially parécian tener resultados funcionales deficientes a largo plazo, ahora

Investigators analyzed the trajectories of functional results in more than 700 HIC or HIV survivors, who had shown very deficient functional results 30 days after the incident.

De ahí se lógró identify que más del 40% de estos pacientes, consiguieron resultados favorablees, al cabo de un año, siendo un tercio, más funcionales e independientes; así también luego de un año, casi dos tercios habian regressado casa y las puntuaciones de calidad de vida showtraban una trajeteria ascendente significativa.

Uno de los mejores resultados, se deben a la prediction de la recovery futura, gracias a la inclusion de los eventos previos hospitalarios, las condiciones preexistentes, y respuestas a terapias modelos.

“El principal mensaje para llevar a casa de este estudio es que el focus de muchos pacientes con HIC debe cambiar”, said the principal author of the study, la Dra. Wendy Ziai, MD, MPH, medical director of the neurovascular laboratory and professor of neurology at Johns Hopkins Hospital, Baltimore, Maryland. He also confirmed, that “the data support longer periods of evaluation before patients with HIC with observation of events in the hospital and the response to therapy before providing a better understanding of the recovery a largo plazo“.

¿Profecía self-fulfilled?

Historically, the HIC forecast was realized at the moment of entry and most of the models predict short-term results. Most of the studies don’t even describe it recovery a largo plazo entre las personas con discapacidad grave initial.

The majority of prognostic models include initial HIC severity factors, but they do not take into account comorbidities, hospital interventions and complications, while the HIV classification scales usually incorporate only the initial HIV volume, pero no la expansion, la reduction del volumen o la hidrocephalia de la HIV, que “también pueden afectar la recuperación”, sostuvo.

“The majority of patients with HIC who die in the hospital do so after taking the decision to withdraw vital support measures, due to the perception of providers of a high probability of bad results in the long term,” he said. , left Dra. mourning

“Estas decisions pueden resultar en una profecía autofulplida de malos resultados”, he continued, diciento que, “incluso las orderes de no resucitar se asocian con un major risego de mortality y pueden reducir la probabilidad de un resultato funcional favorable cuando se instituyen early”.

Before evaluating the trajectories of results 1 year after HIC, the researchers realized a post hoc longitudinal analysis of 500 patients with spontaneous obstructive HIV randomly assigned to intraventricular alteplase or placebo in the CLEAR-III trial and 499 patients with supratentorial HIC grande espontánea sin HIV obstructivea. HIV asignada aleatorimente a trombólisis estereotáctica o atención médica estándar en el ensayo MISTIE.

Ambos ensayos fueron neutrales para la main variable de resultato funcional mejorado, pero encontraron significados reducciones en la mortality en los groups de tratamiento activo a los 180 días y al año, respectively.

The final group cohort included 715 patients who survived until day 30 with a score on the modified Rankin scale (mRS) of 4 (29.5%) or 5 (69.5%). The median age was 60.3 years, 58% were men, 68.6% were white, 24.3% were black and 13.7% were Hispanic.

The initial characteristics include age, sex, race, ethnic origin, comorbidities related to cerebrovascular accident, the score of the Glasgow coma scale and the score of the cerebrovascular accident scale of the National Institutes of Health ( NIHSS), as well as los vúmenes de hematoma (medidos al ingreso, en la stability de ICH, y, IVH, en al final del tratamiento y al día 30 desde la scripción en ambos ensayos).

The primary outcome measure was mRS of 1 year, with evaluations realized in both trials at days 30, 180 and 365.

The patients are divided into two groups based on a 1-year result of “good” (mRS 0 – 3) and “poor” (mRS 4 – 6).

Los resultados secundarios fueron la mortality a 1 año, la retirada del tratamiento de soporte vital, el alta domiciliaria y la puntuación de la Escala analogógica visual europea de calidad de vida.

Avoid the early withdrawal of life support therapies

At the end of 1 year, 18% of the participants had died, 43% had reached mRS scores of 0 to 3, and 64.6% of the survivors had returned home with a median of 98 (52 to 302). días posteriores

Among the 308 patients who recovered with a good result at the end of 1 year, 95.4% returned home. In addition, the 41% who had a bad persistent result at the end of 1 year were also able to return home.

En los modelos ajustados para la cohorte combineda, los factors de la siguiente tabla en el día 30 se asociaron con la falta de recuperación.

Graphic, taken from MedScape.

Por otro lado, la resolution de la HIC (Posibilidad de Ocurrencia ORa, 1.82; IC del 95 %, 1.08 – 3.04) y la HIV (ORa, 2.19; IC del 95 %, 1.02 – 4.68) en el día 30 se asoció con una buena recuperación. Salir.

Los factores adicionales asociados con un resultado deficiente inclueron una pressure de fusión cerebral inferior a 60 mm, sepsis, mechanical ventilation prolongedada y la necesidad de monitorear la presión intracrane.

The three-day event models “strongly predict” the 1-year outcome (AUC, 0.87; 95% IC, 0.83 – 0.90), with a “significantly improved discrimination” compared to the models que utilización factores de gravedad initiales solos (AUC, 0.76; IC del 95 %, 0.71 – 0.80), informan los autores.

“Although there are still no proven interventions for patients with HIC that definitively improve results, the effective reduction of hematoma volume, according to studies in these clinical trials, is significantly associated with a better capacity to discriminate between patients who achieve functional recovery final al cabo de 1 año y los que no”, commented Ziai.

The findings “resaltan the importance of promoting aggressive treatment and avoiding the early withdrawal of life support therapies in the acute phase after HIC,” he said.

Implications that change practice

El Dr. Magdy Selim, MD, PhD, professor of neurology at the Beth Israel Deaconess Medical Center in Boston, Massachusetts, said that the results of the study have “implications that change practice”, the recovery after ICH is “slow, but it is possible that muchos pacientes se recuperen con cuidado y tiempo agresivos,” he said.

Los pacientes y las familias “must be informed that the effects of aggressive measures may not be evident in a short period of time and that patients with HIC require patience from their providers and caregivers,” said Selim, who did not participate in the study.

Anotó that the majority of deaths after HIC are the result of the early withdrawal of attention “due to the perception of a long-term mal result for the part of the treating doctors and the family”. The findings of the study “señalan claramente que los medicos y las familias deben tener cuidado antes de limitar la attention agresiva since el principio, para maximizar las possibilities de recuperación de los pacientes”.

Fuente consultada aquí.