{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,28]],"date-time":"2026-09-28T19:17:20Z","timestamp":1790623040562,"version":"4.1.0"},"reference-count":28,"publisher":"Ovid Technologies (Wolters Kluwer Health)","issue":"12","content-domain":{"domain":["www.ahajournals.org"],"crossmark-restriction":true},"short-container-title":["Stroke"],"published-print":{"date-parts":[[2021,12]]},"abstract":"<jats:sec>\n            <jats:title>Background and Purpose:<\/jats:title>\n            <jats:p>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).<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Methods:<\/jats:title>\n            <jats:p>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.<\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Results:<\/jats:title>\n            <jats:p>\n              Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (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\u20134.3],\n              <jats:italic>P<\/jats:italic>\n              &lt;0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3\u20130.4],\n              <jats:italic>P<\/jats:italic>\n              &lt;0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152\u2013229],\n              <jats:italic>P<\/jats:italic>\n              &lt;0.0001). Early WOLST (&lt;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.\n            <\/jats:p>\n          <\/jats:sec>\n          <jats:sec>\n            <jats:title>Conclusions:<\/jats:title>\n            <jats:p>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.<\/jats:p>\n          <\/jats:sec>","DOI":"10.1161\/strokeaha.121.035233","type":"journal-article","created":{"date-parts":[[2021,9,29]],"date-time":"2021-09-29T09:16:09Z","timestamp":1632906969000},"page":"3891-3898","update-policy":"https:\/\/doi.org\/10.1161\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":46,"title":["Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness"],"prefix":"10.1161","volume":"52","author":[{"ORCID":"https:\/\/orcid.org\/0000-0003-0352-5913","authenticated-orcid":true,"given":"Ayham","family":"Alkhachroum","sequence":"first","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio J.","family":"Bustillo","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Negar","family":"Asdaghi","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Erika","family":"Marulanda-Londono","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Carolina M.","family":"Gutierrez","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0670-2647","authenticated-orcid":true,"given":"Daniel","family":"Samano","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Evie","family":"Sobczak","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dianne","family":"Foster","sequence":"additional","affiliation":[{"name":"Regional Director Quality Improvement, American Heart Association (D.F.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohan","family":"Kottapally","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Amedeo","family":"Merenda","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sebastian","family":"Koch","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Jose G.","family":"Romano","sequence":"additional","affiliation":[{"name":"Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.)."},{"name":"Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., 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