Prediction of in-hospital mortality after first-ever stroke: the Lausanne Stroke Registry

doi:10.1016/S0022-510X(99)00117-3

Journal of the Neurological Sciences

Volume 166, Issue 2, 1 July 1999, Pages 107-114

https://doi.org/10.1016/S0022-510X(99)00117-3 Get rights and content

Abstract

We aimed to study in-hospital mortality after a first-ever stroke (brain infarction or parenchymatous hemorrhage) and to determine its predictors using easily obtainable variables. The main outcome measure was vital status at hospital discharge. Clinical features and type of stroke, with a particular emphasis on age, stroke topography and presumed causes of stroke, were studied in 3362 consecutive patients from the Lausanne Stroke Registry. Overall mortality was 4.8%. Brain hemorrhage mortality was 14.4% (48/333) and brain infarction mortality was 3.70% (112/3029). Localizations with high mortality included infratentorial (17.5%) and deep hemispheric (15.9%) territories for brain hemorrhage and, for brain infarction, multiple localizations in the posterior circulation (18.4%) and large middle cerebral artery territory (15.5%). Presumed causes of stroke associated with high mortality included saccular aneurysm (58.3%) and hypertensive arteriopathy (13.0%) for brain hemorrhage and, for brain infarction, dissection (10.4%), arteritis (8.3%), hematologic conditions (6.7%) and coexisting arterial and cardiac sources of embolism (5.2%). Multivariate logistic analysis showed that impaired consciousness on admission and limb weakness were good predictors of mortality for brain hemorrhage, while impaired consciousness and the cumulative effect of progressive worsening, limb weakness, left ventricular hypertrophy, past history of cardiac arrhythmia and previous transient ischemic attack were predictors of mortality for brain infarction. Age was not an independent predictor of stroke mortality, but for brain infarction the number of cumulative factors considered in the model increased with age. Our study shows that several factors associated with death risk are available during the first few hours after onset of stroke. Age alone is not critical, although its interaction with other factors should be considered.

Introduction

Detailed knowledge of in-hospital mortality and its predictors after first-ever stroke has clinical and research implications, including: (1) having a reliable prognosis to give to the relatives; (2) defining therapeutic goals; (3) planning of clinical trials; and (4) establishing Do-Not-Resuscitate orders in stroke patients.

The aims of this study were to provide further information on stroke mortality and to determine predictors of in-hospital mortality after first-ever stroke, using easily obtainable variables.

Data from The Lausanne Stroke Registry have been published previously. Although this is not a population-based stroke registry it gives a good estimate of the stroke-related problems in patients admitted to a primary care center, since the hospital (Centre Hospitalier Universitaire Vaudois) is the sole acute-care facility for stroke in the Lausanne area [1].

Section snippets

Methods

The data of 3362 consecutive patients with first stroke (brain infarction or brain hemorrhage) admitted to the Centre Hospitalier Universitaire Vaudois since 1978 have been coded prospectively into a computerized stroke registry. The methodology of the Lausanne Stroke Registry has been described in detail previously [1].

The study end-point was vital status (alive, dead) at hospital discharge (discharge from hospital occurs when the patient’s condition is stable). Specifically, we studied death

Mortality and age

Median age was 66 years (range 16–97, mean 62.8, standard deviation 14.8). There were 2075 men and 1287 women. Overall in-hospital mortality was 4.8% (160/3362). Ischemic stroke was diagnosed in 3029 patients and primary hemorrhagic stroke in 333 patients. Brain hemorrhage had significantly higher mortality than brain infarction [14.4%, 48/333 (95% CI=10.8–18.7) versus 3.70%, 112/3029 (95% CI=3.1–4.4), P<0.0005], the difference being evident in each age group (Table 1).

For brain hemorrhage

Discussion

Overall, in-hospital mortality was 4.8%, 14.4% for brain hemorrhage and 3.7% for brain infarction. These figures are lower than in several other studies [4], [5], [6], [7], [8]. The reason for this is unclear, but it may be partially related to improved care in the acute phase, and to our referral patterns, including a negative bias for rapidly lethal strokes, as these patients die before reaching the hospital [1]. Increased detection of less severe cases may be an alternative explanation

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Other sub-Saharan African authors have described a mortality of 9.5 and 15.5% in patients followed-up exclusively in a Neurology clinic, as in our study [16,17]. Western studies that included both ischemic and hemorrhagic strokes reported in-hospital mortality rates of between 4.8% [18] and 16% [19]. A multicentric Asian study similar to the current study reported 12.5% [20].
Stroke is one of the most common causes of high mortality rates in Africa with many unknown aspects around its prognosis. In this study we aim to describe stroke characteristics and in-hospital mortality of stroke in Parakou.
This is a retrospective cohort study including all stroke patients admitted to the Department of Neurology at Parakou Teaching Hospital from January 1, 2013 through to December 31, 2019. Clinical data, vascular risk factors, stroke subtype and outcome data were recorded. The in-hospital case-fatality and its associated factors were determined. The study was approved by the Local Ethics Committee of Biomedical research and has been registered under the unique indentifying number researchregistry5687 and is available at https://www.researchregistry.com/browse-the-registry#home/
Stroke cases represented 51.5% of all patients. There were 372 patients included in the study with a mean age of 58.2 ± 14.2 years. The sex ratio was 1:3. Ischemic stroke accounted for 40.3%, intracerebral hemorrhage 30.4%, and unknown 29.3%. The main vascular risk factors were hypertension (69.1%), alcoholism (23.9%) and diabetes mellitus (16.9%). The mean NIHSS at admission was 9.4 ± 5.7 and the length of hospital stay was 9.0 ± 7.3. The most common complications recorded during the acute phase were swallowing disorders (10.2%), pneumonia (9.1%) and urinary tract infections (8.3%). The in-hospital case fatality was 6.2% and was associated with loss of consciousness (p = 0.0001), high NIHSS on admission (p = 0.001), fever (p = 0.0001), swallowing disorders (p = 0.001) and leukocytosis (p = 0.021). On discharge, 27.6% were independent and 97.8% were on antihypertensive drugs.
The in-hospital stroke mortality was close to that reported by other studies in Africa.
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Stroke vascular territories may influence response to thrombolysis, although supporting data are limited. The aim of the study was to test the hypothesis that the current available prediction scores might inaccurately estimate the risk of symptomatic intracerebral hemorrhage (SICH) after intravenous thrombolysis in patients with posterior circulation stroke.
We applied the Safe Implementation of Thrombolysis in Stroke (SITS) SICH risk score to data from four hospital-based stroke registries. Patients were grouped according to anterior or posterior circulation stroke. The main outcome measure was SICH per various definitions. Performance of the risk score was assessed with the c statistic.
Data of 518 thrombolyzed patients (434 anterior, 84 posterior) were studied. The overall rate of SICH varied from 3.5% to 6.9% depending on the SICH definition. Patients with posterior circulation stroke were less likely to have post-thrombolysis SICH per NINDS (P = 0.042), per ECASS II (P = 0.013), or any ICH (P = 0.001), and their rate of SICH was markedly lower than predicted (1.2% versus 7.1% by the NINDS definition; 0% versus 4.8%, ECASS II; 0% versus 1.6%, SITS-MOST). The SITS SICH risk score shows moderate model discrimination across the SICH definitions, with c statistic ranging from 0.64 to 0.70.
The risk of SICH after intravenous thrombolysis in patients with posterior circulation stroke was low enough to render the SITS SICH risk score or other similar prediction models unnecessary. Awareness of stroke territory might help clinicians judiciously use the risk assessment models.
Hypoalbuminemia Predicts Acute Stroke Mortality: Paul Coverdell Georgia Stroke Registry
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Mortality remains unacceptably high among patients hospitalized for acute stroke. Additional knowledge about factors that contribute to mortality after stroke is important for instituting therapies to lower mortality. We sought to determine the factors that predict mortality in patients hospitalized for acute stroke.
In all, 1477 consecutively admitted patients with acute stroke in 34 hospitals in the state of Georgia participating in the Paul Coverdell Georgia Stroke Registry during a 3-month period (December 1, 2001-February 28, 2002) were identified by retrospective chart review using primary or secondary International Classification of Diseases, Ninth Revision codes. Of patients, 31% were black, 65% were white, and 58% were women. We determined inhospital mortality after admission for acute stroke in this representative group of patients.
There were 154 (10%) inhospital deaths among the 1477 patients admitted with acute stroke. Univariate analysis showed that mortality was associated with older age (P = .0008), stroke type (P = .0051), Glasgow Coma Scale score less than 9 (P < .0001), decreased serum albumin (P = .0001), elevated creatinine (P = .0067), and elevated blood glucose (P = .0063). In the multivariate analysis, independent risk factors for mortality after acute stroke included older age (P = .004), stroke type (P = .0007), Glasgow Coma Scale score less than 9 (P < .0001), and decreased serum albumin (P = .0003). There was no relationship between race and inhospital mortality (P = .9041). In addition, there was no association between independent predictors and race.
In addition to previously recognized predictors of inhospital mortality, we found hypoalbuminemia to be an independent predictor of mortality in a biracial cohort of patients with acute stroke.
Ischemic Stroke and Anoxic-Ischemic Encephalopathy
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Impairment of consciousness with regional ischemia (strokes) depends on dysfunction of specific brain regions involved in alertness and higher functions. These structures can be affected directly by the lack of perfusion, by remote synaptic or metabolic suppression (diaschisis), by mass effect with herniation, or by complications such as seizures, superimposed infections, respiratory or hemodynamic effects, metabolic derangements, or adverse effects of drugs. Acute ischemia in the middle cerebral artery territory of the dominant hemisphere can result in temporary unresponsiveness or decreased alertness. MRI is superior to computed tomography (CT) scanning that helps in identifying territories of stroke at an early stage. Anoxic–ischemic encephalopathy or postresuscitation encephalopathy refers to brain dysfunction due to transient circulatory arrest. The neurological prognosis after cardiopulmonary resuscitation (CPR) or hypothermic therapy can be detected by electrophysiological tests, neuroimaging, or biochemical testing. The chapter also summarizes various vascular syndromes and their effects on consciousness and its components.
Factors influencing in-hospital mortality and morbidity in patients treated on a stroke unit
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Citation Excerpt :
In addition, restricting analyses to patients with ischemic stroke did not change the attributable risk estimates substantially (data not shown). Previous studies have demonstrated that several factors independently increase the risk of death or poor outcome in acute stroke.2,12–20 Our study, however, differs from these investigations in several ways.
To determine the extent that demographics, clinical characteristics, comorbidities, and complications contribute to the risk of in-hospital mortality and morbidity in acute stroke.
Data of consecutive patients admitted to 14 stroke units cooperating within the Berlin Stroke Register were analyzed. The association of demographics, clinical characteristics, comorbidities, and complications with the risk of in-hospital death and poor outcome at discharge was assessed, and independent attributable risks were calculated, applying average sequential attributable fractions.
In a 3-year period, 16,518 consecutive patients with ischemic or hemorrhagic stroke were documented. In-hospital mortality was 5.4%, and 45.7% had a poor outcome (modifed Rankin Scale score ≥3). In patients with length of stay (LOS) ≤7 days, 37.5% of in-hospital deaths were attributed to stroke severity, 23.1% to sociodemographics (age and prestroke disability), and 28.9% to increased intracranial pressure (iICP) and other complications. In those with LOS >7 days, age and stroke severity accounted for 44.1%, whereas pneumonia (12.2%), other complications (12.6%), and iICP (8.3%) contributed to one-third of in-hospital deaths. For poor outcome, attributable risks were similar for prestroke disability, stroke severity, pneumonia, and other complications regardless of the patient's LOS.
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Prediction of in-hospital mortality after first-ever stroke: the Lausanne Stroke Registry

Abstract

Introduction

Section snippets

Methods

Mortality and age

Discussion

The Lausanne Stroke Registry: analysis of 1000 consecutive patients with first stroke

Stroke

Arterial territories of human brain: brainstem and cerebellum

Neurology

Arterial territories of human brain: cerebral hemispheres

Neurology

Do-not-ressuscitate orders in acute stroke

Neurology

Multinational comparisons of stroke epidemiology. Evaluation of case ascertainment in the WHO MONICA stroke study

Stroke

Predictive factors of in-hospital mortality in 986 consecutive patients with first-ever stroke

Cerebrovasc Dis

The Tel Aviv stroke registry. 3600 consecutive patients

Stroke

Subtypes of ischemic stroke. A hospital based stroke registry in Taiwan (SCAN IV)

Stroke

Stroke incidence, case fatality, and mortality in the WHO MONICA Project

Stroke

The influence of age on stroke outcome: the Copenhagen stroke study

Stroke

The natural history of internal carotid artery and vertebral-basilar artery occlusion

Neurology

Temporal profile (clinical course) of acute vertebro-basilar system infarction

Stroke

Prognosis of acute stroke

Neurology

Outcome following occlusion of the middle cerebral artery

Acta Neurol Scand

Short term prognosis of vertebro-basilar ischemic stroke

Cerebrovasc Dis

Spontaneous carotid dissection with acute stroke

Arch Neurol

Studies on cerebrovascular strokes II. Clinical findings and short term prognosis in a stroke material

Acta Med Scand

Survival and recurrence following stroke—The Framingham Study

Stroke

Predicting the outcome of acute stroke: a prognostic score

J Neurol Neurosurg Psychiatry

Multivariate analysis of improvement and outcome following stroke rehabilitation

Arch Neurol

Prediction of intracerebral hemorrhage survival

Ann Neurol

Survival following stroke. A prospective population-based study of 438 hospitalized cases with prediction according to subtype, severity and age

Acta Neurol Scand