Withdrawal of life-sustaining treatment mediates mortality in patients with intracerebral hemorrhage with impaired consciousness

Ayham Alkhachroum, Antonio J. Bustillo, Negar Asdaghi, Erika Marulanda-Londono, Carolina M. Gutierrez, Daniel Samano, Evie Sobczak, Dianne Foster, Mohan Kottapally, Amedeo Merenda, Sebastian Koch, Jose G Romano, Kristine O’Phelan, Jan Claassen, Ralph L Sacco, Tatjana Rundek

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1 Scopus citations


BACKGROUND AND PURPOSE: Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST). METHODS: Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition. RESULTS: Among 37613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1–4.3], P<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3–0.4], P<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152–229], P<0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate. CONCLUSIONS: In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

Original languageEnglish (US)
Pages (from-to)3891-3898
Number of pages8
Issue number12
StatePublished - Dec 1 2021


  • Aphasia
  • Cerebral hemorrhage
  • Consciousness
  • Length of stay
  • Logistic models

ASJC Scopus subject areas

  • Clinical Neurology
  • Cardiology and Cardiovascular Medicine
  • Advanced and Specialized Nursing


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