title: How patients die after intracerebral hemorrhage.
abstract: BACKGROUND
  Severity of illness scores predict all-cause mortality after intracerebral hemorrhage (ICH), but do not differentiate between proximate mechanisms or predict the timing. We hypothesized that death by neurologic criteria [brain death (BD)], withdrawal of life support, and cardiovascular death would be distinct after ICH.
  
  
  METHODS
  We prospectively enrolled patients with spontaneous ICH without underlying vascular malformation or neoplasm. We recorded clinical data and the proximate mechanism of death (BD, withdrawal of life support, cardiovascular death, or other cause). Time to death was compared with Kaplan-Meier methods (log-rank test). Data are median (IQR).
  
  
  RESULTS
  Among 89 patients, 15 had withdrawal of life support, 5 had BD, 2 died from cardiac arrest, and 3 died from other causes. Among patients who died, ICH score, age, Glasgow Coma Scale, NIH Stroke Scale, and proximate cause were not associated with the proximate mechanism of death. The time to death was different (P < 0.001) depending on the proximate mechanism. Patients with BD died 1 [0-1] 1 day after ICH, withdrawal of life support led to death 5 [1-13] days after ICH, cardiac death occurred 35 [35-85] days after ICH, and other causes led to death 33 [26-33] days after ICH. Among patients where life support was withdrawn, a higher ICH score on admission was related to earlier death (P = 0.002).
  
  
  CONCLUSIONS
  Proximate mechanisms of death after ICH occur at distinct times. Withdrawal of life support leads to earlier death in patients with a higher severity of injury. Medical causes of death can be effectively prevented after ICH.
authors.affiliation: Northwestern University, 710 N Lake Shore Drive 11th Floor, Chicago, IL 60611, USA. a-naidech@northwestern.edu
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Naidech
authors.forename: Richard A
authors.initials: RA
authors.lastname: Bernstein
authors.forename: Sarice L
authors.initials: SL
authors.lastname: Bassin
authors.forename: Rajeev K
authors.initials: RK
authors.lastname: Garg
authors.forename: Storm
authors.initials: S
authors.lastname: Liebling
authors.forename: Bernard R
authors.initials: BR
authors.lastname: Bendok
authors.forename: H Hunt
authors.initials: HH
authors.lastname: Batjer
authors.forename: Thomas P
authors.initials: TP
authors.lastname: Bleck
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001926:Brain Death; D002423:Cause of Death; D002543:Cerebral Hemorrhage / Q000401:mortality*; D003422:Critical Care / Q000706:statistics & numerical data*; D003643:Death; D005066:Euthanasia, Passive / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008020:Life Support Care / Q000706:statistics & numerical data*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D016414:Resuscitation Orders; D012720:Severity of Illness Index