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Survival among hemorrhagic stroke patients treated at comprehensive stroke centers (CSC) is higher than among those treated at primary stroke centers or other hospitals, a study found.

Compared with patients treated at non-stroke centers or primary stroke centers, patients treated at CSCs had a 7% overall reduced risk of death at 90 days, and the risk reduction was greatest for patients whose strokes were due to aneurysm.

Researchers examined 90-day survival data for close to 37,000 hemorrhagic stroke patients treated between 1996 and 2012 at 87 New Jersey hospitals, including 14,788 patients (40%) treated at 13 comprehensive stroke centers. The study was the largest ever conducted in the U.S. assessing the effect of CSC care on brain-bleed stroke outcomes.

Patients with subarachnoid hemorrhage (SAH) treated at CSCs had a 27% reduction in death, compared with patients with aneurysm-related strokes treated at non-CSC facilities, of Rutgers-Robert Wood Johnson Medical School, in New Brunswick, N.J., and colleagues wrote online May 6 in the

"The survival benefit associated with treatment at a comprehensive stroke center was really driven by subarachnoid hemorrhage," McKinney told MedPage Today. "Patients treated at CSCs were significantly more likely to receive neurosurgical and endovascular treatments."

About 13% of Strokes Are Hemorrhagic

Treatment at a CSC has repeatedly been shown to improve survival in ischemic stroke patients, but far less research has been done examining outcomes among patients with strokes caused by brain bleeds, which account for about 13% of all strokes, McKinney explained.

"Comprehensive stroke centers are designed to have 24/7 access to neurosurgeons, neuroradiologists, and other personnel that can provide a full spectrum of diagnostic and treatment options," he said.

Using the Myocardial Infarction Data Acquisition System (MIDAS) administrative database, the researchers identified all intracerebral hemorrhage (ICH) and SAH admissions at the 87 New Jersey hospitals between 1996 and 2012. Multivariate logistic regression models were used to adjust for mortality confounders and also to adjust for confounders related to the comparison of treatments among hospital types.

Two sensitivity analyses were conducted, including one that included only data from 2007 -- when New Jersey first began designating CSCs -- and later, and another which evaluated hospitals based on 2014 stroke center designations by The Joint Commission.

A total of 52 of the hospitals included in the analysis were primary stroke centers, 13 were CSCs, and 22 were non-stroke centers. Not surprisingly, an increase was seen in the percentage of patients admitted to CSC both for ICH and for SAH during the study.

Neurosurgical procedure rates and 90-day mortality were the primary outcomes measured.

Procedure Rate Much Higher at CSCs

Among the major findings from the procedures analysis:

• Neurosurgical and endovascular interventions were performed more often in CSCs than primary stroke centers or non-stroke centers (18.9% versus 4.7%; P<0.0001).
• Patients treated at CSCs were significantly more likely to undergo craniotomy or craniectomy (odds ratio 1.80; 95% CI 1.55-2.1); insertion or replacement of an external ventricular drainage (EVD), intracranial ventricular shunt, or ICP-monitor (OR 6.05; 95% CI 5.16-7.10); surgical clipping, repair, or occlusion of intracranial aneurysm/vessel (OR 2.98; 95% CI 2.69-3.30); and endovascular embolization or occlusion of a head or neck vessel (OR 17.40; 95% CI 13.01-23.25).
• Neurosurgical and endovascular clipping/repair/occlusion were all associated with lower mortality among patients with aneurysm or vessel bleeds.

The mortality analysis revealed that:

• In-hospital, 30-day, 90-day and 1-year death rates were all significantly lower among patients treated at CSCs.
• After adjustment, CSC admission was associated with a significant reduction in 90-day mortality (OR 0.93; 95% CI 0.89-0.97), and the reduction persisted for up to 1 year.
• Significant improvements in 90-day mortality were not seen in ICH patients treated at CSCs (38%) compared with those treated at other centers (40.3%). However, CSC admission for SAH was associated with a significant reduction in adjusted risk of death (27.1% versus 40.8%; OR 0.73; 95% CI 0.66-0.82).

"We are entering a new era in the organization and delivery of stroke care," McKinney told MedPage Today. "The clear message is that hemorrhagic stroke patients should be transported to and treated at comprehensive stroke centers whenever possible."

From the American Heart Association:

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