Jose Gutierrez, MD, MPH

Bhalla A,Yanzhong Y, Rudd A, and Wolfe, CDA. Differences in Outcome and Predictors Between Ischemic andIntracerebral Hemorrhage: The South London Stroke Register. Stroke. 2013

Stroke is a devastating disease affecting millions of patients worldwide. Stroke outcomes are subject of great interest, especially for comparison of effective therapies and prognostication. In this article, investigators used a large, population-based cohort of patients with incident stroke and followed them over 10 years. Some of the information captured for this analysis included vascular risk factors, level of care and severity during the acute stroke episode, presence of dysphagia and urinary incontinence, stroke subtypes (Ischemic vs. hemorrhagic stroke) and measures of functionality as defined by the Barthel Index and life status. The authors used logistic regression to identify predictor of poor outcome defined as either dead or a Barthel Index of 14 or less.
The authors included 3730 patient, 85% had ischemic stroke. Patient with ICH were more likely to be men, young, and African Blacks while ischemic stroke was more frequent in whites. Patients with ICH had a more severe presentation of acute stroke but were less likely to have prior disability compared to those with ischemic strokes. The predictors for poor outcome varied by stroke subtype and time to follow up. At 1 year, older age, a more severe clinical presentation (defined by Glasgow coma scale, urinary incontinence, dysphagia and Barthel index < 15), atrial fibrillation and diabetes were associated with worse outcome in patient with ischemic stroke while in those with ICH, female sex, Barthel index < 15 at presentation (not at baseline) and urinary incontinence were predictors of bad outcome. At 10 years, only increased age, urinary incontinence, Glasgow coma scale < 13, and atrial fibrillation were predictors of poor outcome while for ICH,  urinary incontinence and age reached statistical significance. Predictors of improvement in Barthel Index from 7 days to 3 months were the presence of ICH as the primary stroke subtype, Glasgow coma scale < 13 and presence of urinary incontinence while older age and female sex were negative predictors of improvement.

These results confirm previous literature that suggests that although patients with ICH have greater short-term mortality that hose with ischemic stroke, if survival is achieved, the outcome might be better. Interestingly, incontinence and dysphagia seem to be good predictors of poor outcome. Whether these factors are surrogate of extent or localization of the injuries remains to be determined. A better understanding of factors promoting recovery and improved outcomes would certainly impact millions of people with stroke and lessen the societal burden of this disabling disease, enhancing the importance of these results.