Mechanical Ventilation for Acute Stroke: A Multi-state Population-Based Study

Lahiri, Shouri; Mayer, Stephan A.; Fink, Matthew E.; Lord, Aaron; Rosengart, Axel J.; Mangat, Halinder S.; Segal, Alan Z.; Claassen, Jan; Kamel, Hooman

doi:10.1007/s12028-014-0082-9

Cited by 70 publications

(72 citation statements)

References 15 publications

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“…In a small prospective study including 58 patients with ischemic stroke in need of mechanical ventilation, the presence of stupor or coma was an independent predictor of mortality [8] , consistent with our own results. In our cohort, the in-hospital mortality of mechanically ventilated patients was 57.1%, which is quite in line with previously published data [18,23] . Strikingly, the percentage of mechanically ventilated patients in our study was exceptionally high (66.6%) as compared to previous studies [6,8] .…”

Section: Discussion and Review Of The Literaturesupporting

confidence: 93%

“…The restraint of many stroke physicians is based on large studies conducted in the 1990s showing catastrophic fatality rates of about 90% in acute stroke patients requiring mechanical ventilation [27,28] . More recent studies report somewhat lower rates, however, still reaching about 70% mortality after 1 year [7,8,18] . In a small prospective study including 58 patients with ischemic stroke in need of mechanical ventilation, the presence of stupor or coma was an independent predictor of mortality [8] , consistent with our own results.…”

Section: Discussion and Review Of The Literaturementioning

confidence: 90%

“…In the remaining 247 patients, the median NIHSS score at admission was 12 (interquartile range [5][6][7][8][9][10][11][12][13][14][15][16][17][18]. Of the 252 patients with ischemic stroke, 97 patients (38.5%) underwent thrombolysis: intravenous thrombolysis with rtPA (85 patients), mechanical thrombectomy (5 patients) or a combination of both according to the 'bridging' concept (7 patients).…”

Section: Resultsmentioning

confidence: 99%

“…Newer studies with recruitment of patients after 12/1999 are scarce; an overview is given in table 2 . Interestingly, the reported mortality rates in these studies vary substantially depending on the originating country, with rather low short-term mortality in Asian countries [16,17] and markedly higher mortality rates up to 70% in studies originating from European countries [7] and the United States [18] . Two possible factors may account for this finding: first, although the incidence of ICH is known to be higher in Asians than in Caucasians, a recent study on racial/ethnic differences in the outcome of ICH patients found lower risk-adjusted, in-hospital mortality for Asian than white patients with ICH [19] .…”

Section: Discussion and Review Of The Literaturementioning

confidence: 98%

“…Consistent with our results, NIHSS was found to predict both in-hospital mortality as well as functional outcome. In contrast, the two large US studies with inclusion of 8,185 and 99,782 stroke patients treated on ICU, respectively, could only draw on administrative data and therefore lacked specific information on stroke severity or stroke treatment [6,18] .…”

Section: Discussion and Review Of The Literaturementioning

confidence: 99%

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Outcome Predictors of Acute Stroke Patients in Need of Intensive Care Treatment

Alonso¹,

Ebert²,

Kern³

et al. 2015

Cerebrovasc Dis

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Background: The prognosis of stroke patients admitted to intensive care units (ICU) is commonly regarded to be poor. However, only limited data regarding outcome predictors are available. Patients and Methods: Out of 4,958 consecutive patients admitted to our stroke unit with the diagnosis of acute stroke, after analysis we identified 347 patients (164 male) in need of ICU management. In-hospital and post-rehabilitation mortality as well as functional outcome at discharge and after rehabilitation were analyzed. Results: Ischemic stroke was diagnosed in 252 patients (72.6%) and intracerebral hemorrhage occurred in 95 patients (27.4%). The mean age in our cohort was considerably high (70.8 years). One hundred patients were comatose at admission. The median NIHSS score at admission in the remaining patients was 12. Apart from stroke-related disturbances of consciousness (47.1%), the most common reasons for ICU treatment were cardiac (23.4%) and respiratory (12.1%) complications or interventional procedures requiring mechanical ventilation (11%). In all, 231/347 patients (66.6%) were mechanically ventilated (mean 84 h). In-hospital mortality (143/347; 41.2%) was associated with old age, poor NIHSS score at admission, intracerebral hemorrhage and mechanical ventilation (p < 0.001 in all). Further, admission to ICU because of stroke-related impairment of consciousness increased in-hospital mortality (p < 0.001). Similarly, poor outcome after rehabilitation was associated with old age (p = 0.029) and mechanical ventilation (p < 0.001). In patients ≥80 years with either intracerebral hemorrhage or need of mechanical ventilation, outcome was unfavorable in nearly any case. However, the overall post-rehabilitation outcome did not differ between patients with intracerebral hemorrhage and ischemic stroke (p = 0.275). Conclusion: The stroke population in our study was associated with an increased early mortality; however, given the same conditions, it was old with a high percentage of patients requiring mechanical ventilation. This did not result in increased in-hospital mortality rates compared to younger and less severely affected cohorts. Thus, ICU management is a life-saving initiative even among the elderly. However, the functional outcome was poor in older patients, thus limiting the benefits of ICU care in these patients.

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Section: Discussion and Review Of The Literaturesupporting

confidence: 93%

Section: Discussion and Review Of The Literaturementioning

confidence: 90%

Section: Resultsmentioning

confidence: 99%

Section: Discussion and Review Of The Literaturementioning

confidence: 98%

Section: Discussion and Review Of The Literaturementioning

confidence: 99%

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Outcome Predictors of Acute Stroke Patients in Need of Intensive Care Treatment

Alonso¹,

Ebert²,

Kern³

et al. 2015

Cerebrovasc Dis

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Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation

Bösel

Niesen²,

Salih

et al. 2022

JAMA

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ImportanceMany patients with severe stroke have impaired airway protective reflexes, resulting in prolonged invasive mechanical ventilation.ObjectiveTo test whether early vs standard tracheostomy improved functional outcome among patients with stroke receiving mechanical ventilation.Design, Setting, and ParticipantsIn this randomized clinical trial, 382 patients with severe acute ischemic or hemorrhagic stroke receiving invasive ventilation were randomly assigned (1:1) to early tracheostomy (≤5 days of intubation) or ongoing ventilator weaning with standard tracheostomy if needed from day 10. Patients were randomized between July 28, 2015, and January 24, 2020, at 26 US and German neurocritical care centers. The final date of follow-up was August 9, 2020.InterventionsPatients were assigned to an early tracheostomy strategy (n = 188) or to a standard tracheostomy (control group) strategy (n = 194).Main Outcomes and MeasuresThe primary outcome was functional outcome at 6 months, based on the modified Rankin Scale score (range, 0 [best] to 6 [worst]) dichotomized to a score of 0 (no disability) to 4 (moderately severe disability) vs 5 (severe disability) or 6 (death).ResultsAmong 382 patients randomized (median age, 59 years; 49.8% women), 366 (95.8%) completed the trial with available follow-up data on the primary outcome (177 patients [94.1%] in the early group; 189 patients [97.4%] in the standard group). A tracheostomy (predominantly percutaneously) was performed in 95.2% of the early tracheostomy group in a median of 4 days after intubation (IQR, 3-4 days) and in 67% of the control group in a median of 11 days after intubation (IQR, 10-12 days). The proportion without severe disability (modified Rankin Scale score, 0-4) at 6 months was not significantly different in the early tracheostomy vs the control group (43.5% vs 47.1%; difference, −3.6% [95% CI, −14.3% to 7.2%]; adjusted odds ratio, 0.93 [95% CI, 0.60-1.42]; P = .73). Of the serious adverse events, 5.0% (6 of 121 reported events) in the early tracheostomy group vs 3.4% (4 of 118 reported events) were related to tracheostomy.Conclusions and RelevanceAmong patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy, compared with a standard approach to tracheostomy, did not significantly improve the rate of survival without severe disability at 6 months. However, the wide confidence intervals around the effect estimate may include a clinically important difference, so a clinically relevant benefit or harm from a strategy of early tracheostomy cannot be excluded.Trial RegistrationClinicalTrials.gov Identifier: NCT02377167

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Hypertension management in elderly with severe intracerebral hemorrhage

Zhao

Yuan

et al. 2021

Ann Clin Transl Neurol

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Objective To explore the effect of individualized blood pressure (BP)‐lowering treatment on the outcomes of elderly patients with severe intracerebral hemorrhage (ICH). Methods We performed an exploratory analysis of Controlling Hypertension After Severe Cerebrovascular Event (CHASE) trial, which was a multicenter, randomized, controlled clinical trial. Patients with severe ischemic or hemorrhagic stroke (defined as GCS ≤ 12 or NIHSS ≥ 11) were randomized into individualized versus standard BP‐lowering treatment in CHASE trial. In this exploratory analysis, patients with severe ICH were included. The primary outcome was the percentage of patients with 90‐day functional independence defined as modified Rankin Scale (mRS) ≤2. Results We included 242 patients with severe ICH in the present analysis, consisting of 142 patients aged <65 years and 100 patients aged ≥65 years. There were significant differences between patients aged ≥65 years and <65 years in the proportion of functional independence (47.9% vs. 15.0%, P < 0.001) and good outcome (73.9% vs. 50.0%, P < 0.001) at day 90. In patients aged ≥65 years, the adjusted individualized BP‐lowering treatment had an unequivocal effect on the functional independence at day 90 (21.6% vs. 8.2%, odds ratio [OR]: 4.309, 95% confidence interval [CI]: 1.040‐17.859, P = 0.044) and improved the neurological deficits at discharge (∆ NIHSS ≥ 4: 64.7% vs. 34.7%, OR: 4.300, 95% CI: 1.599‐11.563, P = 0.004). Interpretation Compared with the younger counterparts, the elderly patients (≥65 years) with acute severe ICH might benefit more from individualized BP‐lowering treatment.

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Mechanical Ventilation for Acute Stroke: A Multi-state Population-Based Study

Cited by 70 publications

References 15 publications

Outcome Predictors of Acute Stroke Patients in Need of Intensive Care Treatment

Outcome Predictors of Acute Stroke Patients in Need of Intensive Care Treatment

Effect of Early vs Standard Approach to Tracheostomy on Functional Outcome at 6 Months Among Patients With Severe Stroke Receiving Mechanical Ventilation

Hypertension management in elderly with severe intracerebral hemorrhage

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