Lothian Audit of the Treatment of Cerebral Haemorrhage (LATCH)

Size: px

Start display at page:

Download "Lothian Audit of the Treatment of Cerebral Haemorrhage (LATCH)"

Homer Nicholson
5 years ago
Views:

1. INTRODUCTION Stroke physicians, emergency department doctors, and neurologists are often unsure about which patients they should refer for neurosurgical intervention.

1 1. INTRODUCTION Stroke physicians, emergency department doctors, and neurologists are often unsure about which patients they should refer for neurosurgical intervention. Early neurosurgical evacuation of supratentorial ICH was not more beneficial than initial conservative management in the STICH trial. 1 This single trial result appears to have had a dramatic effect on neurosurgical practice in the UK. 2 However, the Cochrane systematic review of surgery for spontaneous supratentorial ICH, which includes the STICH trial result, shows that surgery reduces death or dependence (although there was heterogeneity amongst the included trials). 3 Therefore, some patients may not receive an intervention which could be beneficial because of the change in clinical practice since the STICH trial result (despite the Cochrane review s findings). European guidelines do not recommend neurosurgical referral of deep ICH, but do recommend referral of lobar ICH within 1cm of the cortical surface which does not reach the deep basal ganglia, especially if it is causing deterioration in consciousness (GCS 9-12 to 8). The NICE guideline differs slightly, 4 and recommends initial medical treatment of: small deep ICH; lobar ICH without either hydrocephalus or rapid neurological deterioration; a large ICH and significant prior comorbidities before the stroke; a GCS <8 unless this is because of hydrocephalus; posterior fossa ICH. However, randomised controlled trials of posterior fossa (infratentorial) ICH evacuation or CSF drainage have not been performed and these procedures are sometimes used in neurosurgical practice. European and American guidelines recommend that neurosurgical intervention should be considered immediately for people with a >2-3cm cerebellar ICH, especially if it is causing deterioration in consciousness (GCS 9-12 to 8), brainstem compression, or hydrocephalus. 5,6 These uncertainties may result in inappropriate referrals to neurosurgery, or the lack of referral of some patients who might benefit. Admission to a stroke unit is audited in NHS Lothian by the Scottish Stroke Care Audit (SSCA). However, specific standards relating to neurosurgical referral and secondary prevention are not audited. Therefore, with the approval of the relevant individuals the LATCH audit extended the SSCA in NHS Lothian to audit current practice against the NICE and European guidelines. 4,7 However, in view of the uncertainty about whether neurosurgical intervention is beneficial or harmful in each of the categories mentioned above, we simply sought to audit the appropriateness of referral patterns. Version 2 15 July 2013 Page 1 of 9

2 2. AUDIT STANDARDS LATCH audited the following referral criteria in the European and NICE guidelines in its first year, described in this report: 2.1 No need for referral of: small, deep ICH in the basal ganglia or thalamus 5ml in volume 4 lobar ICH without either hydrocephalus or rapid neurological deterioration 7 large ICH and significant prior comorbidities before the stroke (modified Rankin Scale score 3, dementia, or significant cardiorespiratory comorbidity) Referral of: cerebellar ICH 2cm diameter 4 ICH causing brainstem compression on CT/MRI 4 ICH causing hydrocephalus on CT/MRI 4,7 ICH causing deterioration in consciousness GCS 9-12 to 8 7 lobar ICH within 1cm of cortical surface 7 3. METHODS Because this audit concerns itself with people who are not referred to neurosurgery, as well as those who are referred, comprehensive case ascertainment has been necessary. Furthermore, since many of the referral criteria are radiological, review of patients brain imaging has been necessary at the Wednesday stroke imaging meetings held in the Neuroradiology Department at the Western General Hospital. Data collection was performed by members of the LATCH team and associated staff. We defined ICH as, the abrupt symptomatic onset of severe headache, altered level of consciousness, or focal neurological deficit, anatomically referable to a focal collection of blood within the brain parenchyma as observed on imaging or at autopsy, which was not attributable to prior trauma or haemorrhagic conversion of a cerebral infarction. 3.1 Case ascertainment All incident ICH in NHS Lothian, between 1 June May 2011, using the following sources: Death certificates (GRO Scotland) and Procurator Fiscal reports Admissions to all hospitals in the region TIA/stroke clinics Review of all brain CTs in Lothian Collaborative network of the relevant clinicians (see audit protocol on the NHS Lothian intranet) Version 2 15 July 2013 Page 2 of 9

3 3.2 Data collection We reviewed electronic patient records and case notes for all patients diagnosed between 1 June 2010 and 31 May 2011 with spontaneous ( primary ) ICH whilst resident in the Lothian healthboard catchment area. We reviewed the first 72 hours of a patient s care after hospital admission to determine the first occasion on which any of the audit criteria on the preceding page were met for referral or non-referral to neurosurgery and if that referral was made or not. Each patient s Glasgow Coma Scale (GCS) score was recorded at the time of referral to neurosurgery (or on admission if no referral was made). ICH volume was measured using the ABC/2 method. 3.3 Data storage Data are stored on the WTCRF NHS server, accessible to audit staff in NHS Lothian (Western General Hospital, Royal Infirmary, St John s Hospital, Liberton Hospital, Royal Victoria Hospital). 4. RESULTS Definite spontaneous ICH n=166 Secondary ICH n=25 Aneurysm=10 Arteriovenous malformation=5 Cerebral cavernous malformation=2 Tumour=8 Primary ICH n=141 ICH diagnosed before death (with brain imaging) n=137 ICH diagnosed at autopsy n=4 Version 2 15 July 2013 Page 3 of 9

4 4.1 Baseline characteristics of 137 adults with primary spontaneous ICH diagnosed between 1 June May 2011 Characteristic Missing n (%) Value n (%) Age (years); median (IQR) 0 (0) 79 (67-83) Sex (male), (%) 0 (0) 62 (45) History of ischaemic stroke (n,%) 1 (0.7) 25 (18) History of TIA (n,%) 1 (0.7) 14 (10) History of ICH (n,%) 0 (0) 13 (9) History of Dementia (n,%) 0 (0) 32 (23) History of atrial fibrillation (n,%) 1 (0.7) 29 (21) History of hypertension (n,%) 1 (0.7) 91 (67) History of myocardial infarction (n,%) 3 (2) 8 (6) On warfarin at time of ICH (n,%) 14 (10) 30 (22) Antiplatelet drugs prior to admission 1 (0.7) 50 (37) Pre ICH modified Rankin Scale Score 0-2 (independent) 2 (1) 87 (64) ICH Location Lobar Deep Infratentorial Lobar and Deep 0 (0) 17 (12) 51 (37) 67 (49) 2 (1) Hydrocephalus 0 (0) 40 (29) ICH Volume ml median (IQR) 0 (0) 21 (7-50) GCS Score median (IQR) 2 (1) 13 (9-15) Intraventricular haemorrhage (n,%) 0 (0) 71 (52) Version 2 15 July 2013 Page 4 of 9

5 4.2 Flowchart of the audit standards for referral and non-referral to neurosurgery, applied to 137 adults with primary spontaneous ICH diagnosed between 1 st June st May 2011 Patients n=137 Patients met 1 audit standards for referral to neurosurgery n=46 Patients met 1 audit standards for not being referred to neurosurgery n=26 Patients met both standards for referral and non-referral to neurosurgery n=40 Partients met neither standards for referral or non-referral to neurosurgery n=25 Patients referred to neurosurgery n=38 (83%) Patients not referred to neurosurgery n=19 (73%) Version 2 15 July 2013 Page 5 of 9

6 4.3 Audit standards for referral to neurosurgery Note that the 38 patients in the group referred to neurosurgical services may have met more than one of the individual audit standards for referral to neurosurgery. Lobar ICH within 1cm of cortical surface* Cerebellar ICH > 2-3cm diameter* ICH causing brainstem compression ICH causing hydrocephalus* ICH causing deterioration in consciousness from GCS 9-12 to less than or equal to 8 Adults meeting audit standard Audit standard fulfilled (adult referred to neurosurgery); (n, %) (78) 9 8 (89) 6 5 (83) (91) 1 1 (100) * Five patients in total were transferred to the care of a neurosurgeon after being referred: One patient with a lobar ICH that was <1cm from the cortical surface was randomised in the STICH II trial. They were then managed conservatively. One patient with a cerebellar ICH >2-3cm diameter was transferred to DCN HDU. This patient underwent posterior fossa decompression. One patient with a lobar ICH that was <1cm from the cortical surface had hydrocephalus and underwent insertion of a ventricular drain. One patient with hydrocephalus secondary to ICH underwent insertion of a ventricular drain. One patient with a lobar ICH <1cm from the cortical surface and hydrocephalus was transferred to DCN HDU and underwent craniotomy and ICH evacuation. Version 2 15 July 2013 Page 6 of 9

7 4.4 Audit standards for non-referral to neurosurgery Adults meeting audit standard Audit standard fulfilled (adult not referred to neurosurgery); (n, %) Small deep ICH (73) Large ICH with significant 7 5 (71) prior comorbidities Lobar ICH without hydrocephalus or neurological deterioration 4 3 (75) 5. INTERPRETATION This report represents a preliminary attempt to audit the treatment of ICH in NHS Lothian. We audited referral patterns given the uncertainty about the effectiveness of interventions for ICH. We did not specify what we regarded to be satisfactory adherence to our standards for referral, since there are no preliminary data on referral patterns. This report has several key findings: (a) Section 4.2 illustrates how guideline-based audit standards are difficult to apply in practice: the standards did not apply to 25 (18%) patients and 40 (29%) patients met standards for both referral and non-referral and were therefore impossible to audit. (b) 83% of patients meeting at least one criterion for referral were referred. (c) 73% of patients meeting at least one criterion for non-referral were correctly not referred to neurosurgery. This report serves as a baseline assessment of the application of simple ICH audit criteria. They merit discussion with stroke, emergency department, and neurosurgery services, and consideration of the results of the recent STICH II trial, which did not confirm a significant benefit from surgical evacuation of lobar ICH. 7 Version 2 15 July 2013 Page 7 of 9

8 Audit team Rustam Al-Shahi Salman, consultant neurologist (audit lead) Christine Lerpiniere, senior research nurse Neshika Samarasekera, clinical fellow Rosemary Anderson, project coordinator Aidan Hutchison, IT programmer Arthur Fonville, medical student Jamie Loan, medical student Rory Piper, medical student NHS Lothian audit / clinical effectiveness This audit has been endorsed and approved by: Clinical Director, Clinical Neurosciences Chief Nurse and Quality Improvement Team chair, Clinical Neurosciences Clinical Effectiveness Department, NHS Lothian NHS Lothian Caldicott Guardian Version 2 15 July 2013 Page 8 of 9

9 References Mendelow AD, Gregson BA, Fernandes HM, Murray GD, Teasdale GM, Hope DT, Karimi A, Shaw MD, Barer DH; STICH investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial intracerebral haematomas in the International Surgical Trial in Intracerebral Haemorrhage (STICH): a randomised trial. Lancet 2005;365(9457): Kirkman MA, Mahattanakul W, Gregson BA, Mendelow AD. The effect of the results of the STICH trial on the management of spontaneous supratentorial intracerebral haemorrhage in Newcastle. Br J Neurosurg 2008;22(6): Prasad K, Mendelow AD, Gregson B. Surgery for primary supratentorial intracerebral haemorrhage. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD DOI: / CD pub2 The National Collaborating Centre for Chronic Conditions. Stroke: national clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA). NICE guideline CG68. Royal College of Physicians (London), 2008 Broderick J, Connolly S, Feldmann E, Hanley D, Kase C, Krieger D, et al. Guidelines for the management of spontaneous intracerebral hemorrhage in adults: 2007 update: a guideline from the American Heart Association/American Stroke Association Stroke Council, High Blood Pressure Research Council, and the Quality of Care and Outcomes in Research Interdisciplinary Working Group. Stroke 2007;38: Steiner T, Kaste M, Forsting M, Mendelow D, Kwiecinski H, Szikora I, et al. Recommendations for the management of intracranial haemorrhage part I: spontaneous intracerebral haemorrhage. The European Stroke Initiative Writing Committee and the Writing Committee for the EUSI Executive Committee. Cerebrovasc Dis 2006;22: Mendelow AD, Gregson BA, Rowan EN, Murray GD, Gholkar A, Mitchell PM; for the STICH II Investigators. Early surgery versus initial conservative treatment in patients with spontaneous supratentorial lobar intracerebral haematomas (STICH II): a randomised trial. Lancet 2013 May 29 doi: /S (13) Version 2 15 July 2013 Page 9 of 9

Outlook for intracerebral haemorrhage after a MISTIE spell

Outlook for intracerebral haemorrhage after a MISTIE spell David J Werring PhD FRCP Stroke Research Centre, Department of Brain Repair and Rehabilitation, UCL Institute of Neurology, National Hospital