Infection causes more than a quarter of deaths among survivors of intracerebral hemorrhage

A longitudinal analysis of more than 72,000 patients who survived a first-time intracerebral hemorrhage identified infection as the leading cause of death in these patients over a 4-year period, according to findings published in Neurology.

“Spontaneous, non-traumatic intracerebral hemorrhage (ICH) remains the most devastating form of stroke. Within one month of injury, 40% of ICH patients die, and by one year, this number increases to 54%,” the researchers wrote. “While short-term fatality after ICH has decreased due to improved care, long-term mortality remains high. However, the long-term causes for death in the ICH survivor population are currently unclear.”

In addition, no comprehensive analysis of causes of death in ICH survivors has been done, the researchers continued. Lindsey R. Kuohn, BA, of the division of neurocritical care and emergency neurology at Yale School of Medicine, and colleagues therefore aimed to determine long-term mortality among these patients.

The researchers obtained administrative claims from the Healthcare Cost and Utilization Project for a retrospective, longitudinal analysis of adult patients’ outcomes after they were discharged from a hospital in New York, California or Florida following a first-time, spontaneous ICH unrelated to trauma. The follow-up period extended to date or death or last available follow-up point. Data was available from 2005 to 2011 for California and from 2005 to 2014 for New York and Florida.

Any readmission that resulted in death served as the primary outcome. The researchers defined cause of death as the primary diagnosis given at discharge.

Of 104,011 patients who experienced a first-time, spontaneous ICH, 72,432 (70%) survived to discharge and were included in the analysis (mean age, 68 years; 48% female).

Over a median follow-up of 4 years, 18% of ICH survivors (n = 12,753) were readmitted for events that led to death. Cumulative risk for death one year after ICH was 9.5% (95% CI, 9.2-9.7) and the median time to death was 10 months for all patients and 7 months for patients with atrial fibrillation.

Patients who died were older (73 vs. 67 years) than survivors and had a greater number of comorbidities (history of atrial fibrillation [18% vs. 12%], chronic kidney disease [13% vs. 8%], congestive heart failure [11% vs. 6%] and diabetes [25% vs. 21%]). The leading causes of death included infection (34%), recurrent ICH (14%), cardiac disease (8%), respiratory failure (8%) and ischemic stroke (5%).

Of 4,107 infections that resulted in death, most (66%) were due to sepsis, followed by aspiration pneumonia (14%), viral and bacterial pneumonia (11%), other types of infections, including those caused by implants or grafts (6%), and urinary tract infections (3%).

Median time to death varied by cause (infection, 10 months; recurrent ICH or cardiac disease, 17 months; respiratory failure or malignancy, 6 months; ischemic stroke, 8 months). Patients with atrial fibrillation were more likely to die due to ischemic stroke (OR = 2.4; 95% CI, 1.9-2.9) and less likely to die due to recurrent ICH (OR = 0.7; 95% CI, 0.6-0.8).

The results provide additional evidence that the risk for infection “may not be isolated” to only the hospital stay and that infection poses a significant risk for death in long-term follow up, particularly in patients older than 65 years, according to the researchers.

“These findings will help to prioritize interventions aimed [at improving] long-term survival and recovery in ICH survivors,” Kuohn and colleagues wrote.