Improving Outcome After Intracerebral Hemorrhage: Maybe It is the Body, Not the Brain
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EDITORIAL
Improving Outcome After Intracerebral Hemorrhage: Maybe It is the Body, Not the Brain J. Claude Hemphill III1
Ó Springer Science+Business Media New York 2017
Intracerebral hemorrhage (ICH) remains a devastating condition with no convincing treatment of proven benefit. Just this past year, two new large clinical trials failed to confirm a benefit of intensive blood pressure lowering and intraventricular t-PA [1, 2]. This adds to the unfortunate growing list of interventions that have tested strokespecific targets such as early supratentorial hematoma evacuation and hemostatic therapy to reduce hematoma expansion. This was supposed to work, and it has for acute ischemic stroke and aneurysmal subarachnoid hemorrhage. Endovascular embolectomy in patients with reversible focal cerebral ischemia and aneurysm clipping and coiling have fundamentally changed the trajectory and natural history of those stroke subtypes. Interestingly, for ICH, we still believe, and with pretty good reason, that ‘‘good care’’ matters. In fact, limiting care early through a nihilistic approach does lead to worse outcomes. It all makes me wonder whether we have been looking in the wrong place. We have been treating ICH like a stroke, when in fact it is a critical illness. One of the lessons of modern critical care has been that the avoidance of complications and iatrogeny is a treatment itself. The use of low-tidal volume ventilation to limit lung injury in patients with acute respiratory distress syndrome, glucose control with avoidance of hypoglycemia, and sedation ‘‘holidays’’ to decrease delirium are routinely employed treatments in modern intensive care units. A recent trial of the ABCDEF critical care bundle showed & J. Claude Hemphill III [email protected] 1
Department of Neurology, Bldg 1, Room 101, Zuckerberg San Francisco General Hospital, 1001 Potrero Avenue, San Francisco, CA 94110, USA
improved outcome [3]. Interestingly, none of the letters in ABCDEF stand for targeted treatments focusing on the underlying specific primary disease. They relate to an approach designed to limit delirium, mobilize and wean patients from mechanical ventilation, and engage their families in order to avoid the complications of critical illness broadly defined. So what does this have to do with ICH? One possibility lies in the prevention of infectious complications. It is in this context that the manuscript by Morotti provides a new twist into identifying targets for intervention in improving the outcome of ICH patients [4]. Utilizing a highly characterized cohort of over 2000 ICH patients over 20 years, they tested the hypothesis that diminished white blood cell counts on hospital admission were associated with the occurrence of infectious complications. They found that lymphopenia (defined as an absolute lymphocyte count 3) and poor discharge disposition [7]. Another large study of over 500,000 ICH patients from the National Inpatient Sample found that 23% of ICH patients developed nosocomial infections, with the rate actually risi
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