Hemorrhagic Stroke: Better Outcome at Comprehensive Centers

May 13, 2015

Patients with hemorrhagic stroke admitted to comprehensive stroke centers are more likely to be alive at 90 days than patients admitted to other hospitals, a new study has shown.

The study, published online in the Journal of the American Heart Association on May 6, was led by James S. McKinney, MD, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.

"This is the first US evidence showing the benefit of treating hemorrhagic stroke at a comprehensive stroke center," Dr McKinney told Medscape Medical News. "There have been two previous studies from Japan but none before in the US."

The researchers note that comprehensive stroke centers are expected to maintain a neurosurgical team, with diagnostic and interventional neuroradiologists on duty 24 hours per day, 7 days per week. They are also expected to offer "comprehensive" rehabilitation services. The availability of these specialized services is expected to lower mortality and lessen neurologic disability, particularly for patients with complex strokes, including hemorrhagic strokes.

Dr McKinney explained that it is recommended that the sickest stroke patients — those with large vessel ischemic strokes or hemorrhagic strokes — are treated at a comprehensive stroke center. There is good evidence that these centers provide very good care that leads to better outcomes for ischemic strokes, but there has been a paucity of evidence about their performance with hemorrhagic strokes.

"Our data confirms that patients with hemorrhagic stroke should to taken to a comprehensive stroke center."

For the current study, the researchers used the Myocardial Infarction Data Acquisition System (MIDAS) database, which includes data on patients discharged with a primary diagnosis of intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH) from all nonfederal acute care hospitals in New Jersey between 1996 and 2012.

The primary outcome was 90-day all-cause mortality, and out-of-hospital deaths were assessed by matching MIDAS records with New Jersey death registration files.

Overall, 36,981 patients were admitted with a primary diagnosis of ICH or SAH during the study period, of whom 40% were admitted to a comprehensive stroke center. Patients admitted to comprehensive stroke center were more likely to have neurosurgical or endovascular interventions than those admitted to a primary stroke center or a nonstroke center (18.9% vs 4.7%; P < .0001).

The primary outcome showed that patients with a hemorrhagic stroke admitted to a comprehensive stroke center had a lower adjusted 90-day mortality after adjustment for confounding variables, and this was particularly marked for those with SAH.

Table. 90-Day Mortality Rates for Patients With Hemorrhagic Stroke in Comprehensive vs Primary or Nonstroke Centers

Endpoint Comprehensive Stroke Center (%) Primary or Nonstroke Center (%) Odds Ratio (95% Confidence Interval)
All hemorrhagic stroke 35.0 40.3 0.93 (0.89 - 0.97)
ICH 38.0 40.3 0.98 (0.93 - 1.03)
SAH 27.1 40.8 0.73 (0.66 - 0.82)


A secondary analysis showed that 950 patients with hemorrhagic stroke were transferred from a primary or nonstroke center to a comprehensive stroke center during the initial 24 hours of hospitalization. After adjustment for available covariates, these patients had a significantly lower risk for death at 90 days than those not transferred (odds ratio, 0.64; 95% confidence interval, 0.54 - 0.77).

They caution however that they did not have access to patient-level data on stroke severity or neurologic condition at presentation, which may have contributed to some of the observed differences in mortality.

The researchers also point out that in this study, patients with hemorrhagic stroke admitted to comprehensive stroke centers were, on average, 5.2 years younger than those admitted to primary or nonstroke centers, and those transferred from a primary or nonstroke center to a comprehensive stroke center were a mean of 10 years younger than those not transferred in the secondary analysis. They say that this "may reflect an inherent bias against prehospital triage or interfacility transfer of older patients."

Dr McKinney commented: "The hope is that the organization of stroke care will enable prehospital screening by the emergency medical services and ER [emergency room] triage so that the correct patients get to the correct centers."

"Clinicians, especially emergency room physicians, need to be aware of the severity and potential implications of hemorrhagic stroke and try to transfer patients to the hospital most capable of providing the full complement of care. When a person is diagnosed with a hemorrhagic stroke, loved ones should ask about the possibility of a transfer," he added.

He noted that in New Jersey, 40% to 50% of patients with hemorrhagic stroke are already being treated at comprehensive stroke centers. He believes this is higher than the picture across most of the United States.

"New Jersey is somewhat unusual in that it is a predominantly urban area, and we may have enough comprehensive stroke centers," he said. "Our job is to concentrate on appropriate transfer and triage. But in other areas, new comprehensive stroke centers will be needed to be created. This is happening across the country."

This study was funded, in part, by the Robert Wood Johnson Foundation. Dr McKinney has disclosed no relevant financial relationships.

J Am Heart Assoc. Published online May 6, 2015. Full text


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