By Matthew E. Fink, MD

Early, Intensive Rehabilitation Improves Outcome in Patients with Intracerebral Hemorrhage

SOURCE: Liu N, et al. Randomized controlled trial of early rehabilitation after intracerebral hemorrhage stroke: Difference in outcomes within 6 months of stroke. Stroke 2014;45:3502-3507.

At least 30% of strokes in China are caused by intracerebral hemorrhage, compared with approximately 10-15% in North America. There are a huge number of such cases in China, and interventions to reduce the effects would be important, but, to date, no significant therapies have been demonstrated to improve outcome, reduce mortality, or result in improved functional neurologic status. In this large multicenter, randomized, controlled study, with blinded outcome at 3 and 6 months, patients were randomized to receive standard care, which was family-directed physical therapy beginning 1 week after the hemorrhage, or standard care plus early rehabilitation, defined as professional rehabilitation started within 48 hours of hemorrhage. The primary outcome was survival. Secondary outcome measures included health-related quality of life using the SF 36 questionnaire, the modified Barthel index, and the Zung Self-Rated Anxiety Scale.

A total of 243 of 326 eligible patients were randomized (mean age = 59 years; 56% were men). At 6 months, patients who received standard care were more likely to have died (hazard ratio, 4.44), and for all morbidity outcomes, patients who received early rehabilitation had better outcomes, as measured by the SF 36 questionnaire, the modified Barthel index score, and the self-rated anxiety scale scores. The study strongly supports the benefit of early rehabilitation within 48 hours of intracerebral hemorrhage to improve survival and functional outcomes at 6 months in patients who were hospitalized in China. Whether these findings can be generalized to populations outside of China is uncertain, but it should certainly be evaluated and replicated if possible.

CT Angiography Is Most Cost-Effective Definitive Test to Identify Aneurysmin Perimesencephalic Subarachnoid
Hemorrhage

SOURCE: Kalra VB, et al. Cost-effectiveness of angiographic imaging in isolated perimesencephalic subarachnoid hemorrhage. Stroke 2014;45:
3576-3582.

Nontraumatic perimesencephalic subarachnoid hemorrhage is a distinct imaging and clinical entity that is found in approximately 5% of patients with subarachnoid hemorrhage. However, about 10% of these patients will have a hemorrhage caused by a ruptured posterior circulation aneurysm, and controversy exists regarding the most definitive and cost-effective test to use to diagnose these small number of aneurysms. Choices have been digital subtraction angiography, or CT angiography, with and without follow-up evaluation if the initial studies are negative. The authors developed a decision tree based on a meta-analysis of 40 studies in the literature, and performed base case and sensitivity analyses to assess cost-effectiveness of various strategies.

The most cost-effective strategy was to perform initial CT angiography with no follow-up angiographic studies needed in patients who had a clinical picture of perimesencephalic subarachnoid hemorrhage, if the CT angiogram was negative for an aneurysm. Even if one was willing to pay up to $1 million for evaluation, the same strategy remains most cost-effective, that is, an initial CT angiogram with no follow-up study required, assuming that the sensitivity of the initial study is greater than 97.9%. Under no circumstances was digital subtraction angiography felt to be superior, or more cost effective, than CT angiography as an initial study.