Impact and Risk Factors of Sepsis on Long-Term Outcomes After Spontaneous Intracerebral Hemorrhage
Spontaneous intracerebral hemorrhage (sICH) is a severe acute cerebrovascular condition with high morbidity and mortality, particularly among elderly populations in China. Survivors often face long-term functional impairments, raising concerns about factors that may exacerbate outcomes. Among these factors, secondary infections during hospitalization have been a subject of debate. While some studies suggest that infections do not significantly impact functional recovery, others indicate a strong correlation between post-ICH infections and poor prognosis. Specifically, sepsis-associated encephalopathy has been identified as an independent risk factor for nosocomial coma in sICH patients. However, comprehensive clinical studies on the prevalence and long-term impact of sepsis in sICH patients remain scarce. This study aims to address this gap by investigating the incidence, risk factors, and long-term outcomes of sepsis in sICH patients.
The study retrospectively analyzed data from adult patients (≥18 years) admitted to the Neurosurgical Intensive Care Unit of Southwest Hospital between January 2018 and June 2020. The diagnosis of sepsis was based on the Sepsis-3 criteria established in 2016. Patients with chronic organ dysfunction, ICH due to neoplastic or vascular malformation causes, no treatment until discharge, or a history of stroke were excluded. A total of 239 patients were identified, of whom 68 (28.9%) met the Sepsis-3 criteria. These patients were older (mean age 59.6 ± 12.5 years) compared to non-sepsis patients and had worse Glasgow Coma Scale (GCS) scores at admission. Additionally, sepsis patients exhibited a higher incidence of hematoma extending into the lateral ventricles (47.8%) and underwent more invasive procedures, including craniotomy (59.4%), continuous lumbar cistern drainage/lumbar puncture (47.8%), deep vein catheterization (50.7%), and endotracheal intubation/tracheotomy (73.9%). Elevated D-dimer levels were also observed in the sepsis group at admission.
The study found that sepsis significantly increased mortality and poor outcomes in sICH patients. At 28 days post-ICH, the mortality rate was 25.0% in sepsis patients compared to 2.1% in non-sepsis patients. At the 6-month follow-up, the poor outcome rate was 67.2% in the sepsis group, with worse modified Rankin Scale (4.40 ± 1.50) and Glasgow Outcome Scale (2.66 ± 1.53) scores. The peak procalcitonin (PCT) level was significantly higher in the sepsis group (11.13 ± 22.96 ng/mL) compared to the non-sepsis group (0.60 ± 0.85 ng/mL). Univariate and multivariate analyses identified several independent risk factors for sepsis occurrence, including older age, continuous lumbar cistern drainage/lumbar puncture, and endotracheal intubation/tracheotomy. Additionally, sepsis, age, hematoma volume, hematoma extending into the lateral ventricles, craniotomy, deep vein catheterization, and endotracheal intubation/tracheotomy were independently associated with poor outcomes at 6 months.
The study also explored the sources of infection in sICH patients. Among the 128 patients with infections, the lower respiratory tract was the primary site (69.5%), followed by clinical operation-related infections (11.7%), such as catheter-related infections, operative wound infections, and ventilator-associated infections. Bacterial cultures revealed Klebsiella pneumoniae as the most common pathogen (49.0%), and fungal infections were present in 31.4% of cases. The peak infection period occurred 3 to 5 days post-ICH, coinciding with the peak period of brain edema.
Despite advancements in sepsis management in general ICU populations, the impact of sepsis on long-term outcomes in sICH patients remains poorly understood. This study highlights the high frequency of sepsis in sICH patients and its significant association with increased mortality and poor functional outcomes. The findings underscore the importance of early diagnosis and optimized treatment of infections in sICH patients to improve outcomes. Risk factors such as older age, larger hematoma volume, and invasive procedures should be carefully considered in clinical practice. Elevated serum PCT levels during the course of ICH, particularly at 3 to 5 days post-onset, were strongly associated with poor outcomes, suggesting its potential as a prognostic marker.
In conclusion, this study provides valuable insights into the impact of sepsis on long-term outcomes in sICH patients. While the retrospective nature and single-center design limit the generalizability of the findings, the results emphasize the need for further multicenter studies to validate these observations. Early recognition and management of sepsis in sICH patients could significantly reduce mortality and improve functional recovery. The identification of independent risk factors for sepsis and poor outcomes offers a foundation for developing targeted interventions to mitigate these risks.
doi.org/10.1097/CM9.0000000000001954
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