Stroke Training and Awareness Resources (STARs)

The Consultant

The consultant’s task is to consider how to provide prognostic information to families. Families are always keen to know the potential for future recovery and also need to know if there is a likelihood of imminent death. It is important that families are able to speak to the medical team soon after the stroke and have their questions answered as fully as is possible at the time.

  • Predicting outcome in acute stroke can be difficult because the trajectory of  recovery after an acute stroke is not always predictable, especially in patients with intracerebral haemorrhage
  • In many patients full or partial functional recovery is realistically expected and full rehabilitation is appropriate
  • For some patients the  extent of irreversible damage is moderate or unclear and there is associated uncertainty as to the patient’s survival
  • Where there is extensive brain damage ( and often also co-morbidities) and death in a matter of days is likely it is important families know this
Esther had an large  ICH and the volume of the ICH is the best predictor of outcome. However she was fit and well prior to her stroke with no significant pre-morbid predictors.  Probable outcome after an ICH can be predicted on the calculator https://www.mdcalc.com/intracerebral-hemorrhage-ich-score. The consultant concludes that it would have been beneficial to have explained the  prognosis more clearly to her family so that they were aware that she might not survive.
Clearer communication may have taken away some of the shock around the suddenness of Esther’s death. The consultant also reflects on whether there should have been discussion with Esther’s family about organ and tissue donation. Click on this link to access Organ Donation Scotland where you will find information on organ donation, choices and the current law in Scotland. Click this link to access STARs Advancing Module 18 where you will find information on sensitive and effective conversations at end of life care following acute stroke.

To help the family understand the uncertainty around prognosis, providing some facts and figures can help.

T/F quiz: Decide which of the following are true and which are false:

An intra-cerebral haemorrhage (ICH) carries and increased risk of early death compared to an ischaemic stroke.
TRUE: The 30-day mortality for intracerebral haemorrhages is 40-50% while 30-day mortality for ischaemic stroke is around 15%.

The NHISS (stroke severity) is strongly associated with increased mortality.
TRUE: Early death after stroke have a median NIHSS score of 18 but survivors had a mean score of 4.

Presence of a previous stroke is a strong predictor of early death.
FALSE: Previous stroke is a positive predictor of disability but not an independent predictor of early death.

Low GCS post stroke is a predictor of early death
TRUE: A GCS of less than 9 is a predictor, however there are many patients who have a low conscious level that will improve and this is particularly true in ICH.

Page last reviewed: 08 Nov 2021