From the Guidelines
Intracerebral hemorrhage (ICH) is the most fatal form of stroke and carries the poorest prognosis for survival and functional recovery. According to the Canadian Stroke Best Practice Recommendations 1, ICH is associated with high rates of early mortality, with 25-50% of patients dying within the first 30 days. Patients who survive an ICH are often left with moderate to severe persistent functional deficits, which can place a significant burden on families and the healthcare system.
Some of the key factors that contribute to the poor prognosis of ICH include:
- High rates of early mortality
- Significant persistent functional deficits
- Hematoma expansion, which is a predictor of poor outcome
- Presence of a 'spot sign' (i.e. contrast extravasation)
- Early presentation to medical attention
- Anticoagulation use
- Initial hematoma volume
Other types of strokes with poor prognosis include:
- Large vessel occlusions, particularly basilar artery occlusions
- Extensive middle cerebral artery strokes
- Hemorrhagic strokes with intraventricular extension
- Strokes with high initial National Institutes of Health Stroke Scale (NIHSS) scores above 15-20
- Persistent large vessel occlusion despite treatment
- Significant comorbidities like uncontrolled diabetes or heart disease
Early intervention with thrombolysis within 4.5 hours or thrombectomy within 24 hours for eligible patients is crucial, as is admission to specialized stroke units for comprehensive care including blood pressure management, glucose control, and early rehabilitation to improve outcomes 1. However, the decision to treat with thrombolysis should be made with caution, especially in patients with major deficits, due to the risk of symptomatic intracranial hemorrhage.
From the Research
Types of Strokes with the Worst Prognosis
- Intracerebral hemorrhage (ICH) is considered the most devastating type of stroke with the greatest mortality rate 2
- Cardioembolic stroke accounts for 14-30% of ischemic strokes and is a severe condition with high mortality rates 3
- Symptomatic intracranial hemorrhage (SICH) following intravenous thrombolysis is a devastating complication with high mortality rates 4
Characteristics of Strokes with Poor Prognosis
- ICH is often caused by small vessel diseases, such as deep perforator arteriopathy or cerebral amyloid angiopathy 5, 6
- Cardioembolic stroke is often associated with certain clinical features, including sudden onset to maximal deficit, decreased level of consciousness at onset, and co-occurrence of cerebral and systemic emboli 3
- SICH is associated with high mortality rates and is often defined by different case definitions, which can affect the reported rates of SICH 4
Mortality Rates
- The mortality rate for ICH is high, with approximately 15% of strokes worldwide resulting in death 5, 2
- The in-hospital mortality rate for cardioembolic stroke is high, with a reported rate of 27.3% in one study 3
- The mortality rate for SICH following intravenous thrombolysis is also high, with a reported rate of 14.7% in one study 4