{
  "abstract": "Background\n\nIn patients with acute stroke, early withholding or withdrawal of life-sustaining therapies is associated with an increased risk of death. We used practice variation across nine European countries to assess whether this relation may be causal.Methods\n\nWe performed a post hoc analysis of the PREvention of Complications to Improve OUtcome in elderly patients with acute Stroke (PRECIOUS) trial, a randomised clinical trial of metoclopramide, paracetamol, and/or ceftriaxone started within 24 h of symptom onset in older patients with acute ischaemic stroke or intracerebral haemorrhage (ISRCTN82217627). The frequency of early treatment restrictions, defined as those installed within 24 h after randomisation, was calculated per participating country and their relation with the primary outcome 'death at 90 days' was estimated through: 1) adjustment for confounders with regression analysis with inverse-propensity score reweighting; and 2) comparing patients enrolled in countries with and without early restrictions, adjusted for confounders with regression analysis.Findings\n\nOf 1493 patients enrolled in PRECIOUS between 2016 and 2022, 1451/1493 (97%) were included in this analysis, of whom 276/1451 (19%) had an early treatment restriction. The rate of these restrictions ranged from 0% to 48% across the participating countries. Patients with restrictions were more likely to die within 90 days (inverse propensity-weighted odds ratio (OR) 3.39; 95% CI 2.71-4.25). However, there was no difference in the rate of death at 90 days between countries with and those without restrictions (21.3% vs 23.5%, adjusted OR 1.39; 95% CI 0.8-2.39).Interpretation\n\nThe use of treatment restrictions early after stroke varied widely across Europe. Although restrictions were independently associated with an increased rate of death, the comparison of death rates between countries with and those without such restrictions provides no indication that this relation is causal.Funding\n\nEuropean Union's Horizon 2020 research and innovation programme; grant agreement No. 634809.",
  "abstract_shown": true,
  "affiliations": [
    "Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.",
    "Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, the Netherlands.",
    "Department of Neurology, St. Antonius Ziekenhuis, Soestwetering 1, 3543 AZ, Utrecht, the Netherlands.",
    "Department of Neurology, Spaarne Gasthuis, Boerhaavelaan 22, 2035 RC, Haarlem, the Netherlands.",
    "First Propaedeutic Department of Internal Medicine, AHEPA Hospital, Aristoteles University of Thessaloniki, Greece.",
    "Department of Neurology and Neurosurgery, University of Tartu, L. Puusepa 8, 50406, Tartu, Estonia.",
    "Department of Neurology, Oslo University Hospital, Sognsvannsveien 20, 0372, Oslo, Norway.",
    "Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.",
    "Department of Neurology, University of Debrecen, Nagyerdei krt. 98, 4032, Debrecen, Hungary.",
    "Department of Neurology and Stroke Unit, ASST di Mantova, Strada Lago Paiolo 10, 46100, Mantova, Italy.",
    "Department of Neurology and Stroke Unit, ASST Papa Giovanni XXIII, Piazza OMS 1, 24127, Bergamo, Italy.",
    "2nd Department of Neurology, Institute of Psychiatry and Neurology, Sobieskiego 9, 02-957, Warsaw, Poland.",
    "Centre for Clinical Brain Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, EH16 4SB, Edinburgh, United Kingdom.",
    "Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, C Floor, South Block, Queen's Medical Centre, Derby Road, NG7 2UH, Nottingham, United Kingdom."
  ],
  "article_type": "research article",
  "arxiv": null,
  "author_total": 16,
  "authors": [
    {
      "affs": [
        0
      ],
      "name": "Wouter M Sluis",
      "orcid": "0000-0003-3057-2010"
    },
    {
      "affs": [
        1
      ],
      "name": "Wouter A C van Amsterdam"
    },
    {
      "affs": [
        0,
        2
      ],
      "name": "Jeroen C de Jonge"
    },
    {
      "affs": [
        0,
        3
      ],
      "name": "Hendrik Reinink"
    },
    {
      "affs": [
        4
      ],
      "name": "George Ntaios"
    },
    {
      "affs": [
        5
      ],
      "name": "Janika Kõrv"
    },
    {
      "affs": [
        6
      ],
      "name": "Anne Hege Aamodt"
    },
    {
      "affs": [
        7
      ],
      "name": "Götz Thomalla"
    },
    {
      "affs": [
        8
      ],
      "name": "Laszlo Csiba"
    },
    {
      "affs": [
        9,
        10
      ],
      "name": "Alfonso Ciccone"
    },
    {
      "affs": [
        11
      ],
      "name": "Iwona Kurkowska-Jastrzebska"
    },
    {
      "affs": [
        12
      ],
      "name": "Malcolm R Macleod"
    },
    {
      "affs": [
        13
      ],
      "name": "Philip M Bath"
    },
    {
      "affs": [
        0
      ],
      "name": "H Bart van der Worp"
    },
    {
      "name": "PRECIOUS investigatorso"
    },
    {
      "name": "PRECIOUS investigators"
    }
  ],
  "bibtex": "https://research.draconitic.com/paper/e8avtb2pdctcz.bib",
  "cited_by": 0,
  "doi": "10.1016/j.lanepe.2026.101894",
  "fulltext_url": "https://europepmc.org/articles/PMC13694901",
  "id": "e8avtb2pdctcz",
  "issns": [
    "2666-7762"
  ],
  "landing_url": "https://europepmc.org/article/MED/42926861",
  "language": "eng",
  "licence": "CC-BY",
  "licence_label": "CC BY",
  "licence_source": "article",
  "licence_url": "https://creativecommons.org/licenses/by/4.0/",
  "metadata_licence": null,
  "native_subjects": [
    [
      "openalex",
      "2739|Palliative Care and End-of-Life Issues"
    ]
  ],
  "openalex": "W7221767023",
  "pdf_url": "https://europepmc.org/articles/PMC13694901?pdf=render",
  "pmcid": "PMC13694901",
  "pmid": "42926861",
  "published": "2026-10-14",
  "publisher": null,
  "ris": "https://research.draconitic.com/paper/e8avtb2pdctcz.ris",
  "sources": [
    {
      "first_seen": "2026-10-30T12:21:18Z",
      "native_id": "MED:42926861",
      "source": "europepmc",
      "url": "https://europepmc.org/article/MED/42926861"
    }
  ],
  "subjects": [
    {
      "field": "medicine",
      "origin": "openalex:2739|Palliative Care and End-of-Life Issues",
      "subfield": "epidemiology-public-health"
    }
  ],
  "title": "Treatment restrictions after acute stroke across nine European countries and their association with 90-day mortality: a post hoc analysis of the PRECIOUS randomised controlled trial.",
  "title_text": "Treatment restrictions after acute stroke across nine European countries and their association with 90-day mortality: a post hoc analysis of the PRECIOUS randomised controlled trial.",
  "type": "peer-reviewed",
  "updated_at": "2026-10-30T12:21:18Z",
  "url": "https://research.draconitic.com/paper/e8avtb2pdctcz",
  "venue": "The Lancet regional health. Europe",
  "versions": []
}