Association of Acute Alteration of Consciousness in Patients With Acute Ischemic Stroke With Outcomes and Early Withdrawal of Care

Abstract

Background and ObjectivesEarly consciousness disorder (ECD) after acute ischemic stroke (AIS) is understudied. ECD may influence outcomes and the decision to withhold or withdraw life-sustaining treatment.MethodsWe studied patients with AIS from 2010 to 2019 across 122 hospitals participating in the Florida Stroke Registry. We studied the effect of ECD on in-hospital mortality, withholding or withdrawal of life-sustaining treatment (WLST), ambulation status on discharge, hospital length of stay, and discharge disposition.ResultsOf 238,989 patients with AIS, 32,861 (14%) had ECD at stroke presentation. Overall, average age was 72 years (Q1 61, Q3 82), 49% were women, 63% were White, 18% were Black, and 14% were Hispanic. Compared to patients without ECD, patients with ECD were older (77 vs 72 years), were more often female (54% vs 48%), had more comorbidities, had greater stroke severity as assessed by the National Institutes of Health Stroke Scale (score ≥5 49% vs 27%), had higher WLST rates (21% vs 6%), and had greater in-hospital mortality (9% vs 3%). Using adjusted models accounting for basic characteristics, patients with ECD had greater in-hospital mortality (odds ratio [OR] 2.23, 95% CI 1.98–2.51), had longer hospitalization (OR 1.37, 95% CI 1.33–1.44), were less likely to be discharged home or to rehabilitation (OR 0.54, 95% CI 0.52–0.57), and were less likely to ambulate independently (OR 0.61, 95% CI 0.57–0.64). WLST significantly mediated the effect of ECD on mortality (mediation effect 265; 95% CI 217–314). In temporal trend analysis, we found a significant decrease in early WLST (<2 days) (R2 0.7, p = 0.002) and an increase in late WLST (≥2 days) (R2 0.7, p = 0.004).DiscussionIn this large prospective multicenter stroke registry, patients with AIS presenting with ECD had greater mortality and worse discharge outcomes. Mortality was largely influenced by the WLST decision.

Commentary: Time to Follow Commands in Severe Traumatic Brain Injury Survivors With Favorable Recovery at 2 Years

“…Unfortunately, in the NCCU, WLST is often driven by factors that are either nonmedical or temporary. 2,6,7 This occurs despite the fact that multiple studies, including the current article, have shown that most patients with severe TBI have favorable outcomes. 8 We feel that this manuscript adds meaningfully to the growing body of evidence that the science of early prognostication in the NCCU is lacking for even our most common diseases and thus WLST should rarely be entertained in the intensive care unit.…”

“…Unfortunately, in the NCCU, WLST is often driven by factors that are either nonmedical or temporary. 2,6,7 This occurs despite the fact that multiple studies, including the current article, have shown that most patients with severe TBI have favorable outcomes. 8…”

“…2,3 In one study, 86% of patients with severe TBI who died in the intensive care unit did so because of WLST. 7 Prognostication is difficult, and the decision for WLST should be made with extreme caution to avoid self-fulfilling prophecies. Unfortunately, in the NCCU, WLST is often driven by factors that are either nonmedical or temporary.…”

Predictors and Temporal Trends of Withdrawal of Life-Sustaining Therapy After Acute Stroke in the Florida Stroke Registry

“…We found higher rates of WLST in hemorrhagic strokes when compared to ischemic stroke; consistent with prior literature. These higher rates might in part be related to impaired level of consciousness, cerebral edema, and herniation syndromes that are seen more commonly after hemorrhagic strokes (9–11). The rates of WLST were stable overtime in comparison to the mortality rates (in decline), highlighting the limitation of the current prognostication practices.…”

“…WLST is more commonly seen after ICH and SAH than AIS (9)(10)(11). Factors such as age, stroke severity, and impaired level of consciousness may influence WLST decisions (10)(11)(12)(13). The temporal trends and predictors of WLST decision during hospitalization are not well studied.…”