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

There is at present no clear indication for surgical removal of intracerebral haemorrhage (ICH) in the majority of patients. With deterioration from an initially good level of consciousness, many surgeons would agree that removal is life saving. The question is whether or not surgical removal of clot improves the ultimate outcome in patients who are stable or even improving. Improvement in function is based on the concept of a penumbra around an ICH. There is now mounting evidence that there is a penumbra of functionally impaired, but potentially reversible, neuronal injury surrounding a haematoma. A pro-active approach must, therefore, be maintained in the management of these patients to salvage as much of this brain as possible. Alert patients with small (<2 cm) haematomas and moribund patients with extensive haemorrhage may not require surgical evacuation Indications for clot removal in patients between these extremes are controversial. Current practice favours surgical intervention in the following situations: (i) superficial haemorrhage, (ii) clot volume between 20-80 ml; (iii) worsening neurological status; (iv) relatively young patients; (v) haemorrhage causing midline shift/raised ICP; and (vi) cerebellar haematomas >3 cm or causing hydrocephalus. A large multicentre prospective randomised controlled trial (International Surgical Trial in Intracerebral Haemorrhage) is currently underway to determine if early clot evacuation will lead to a better neurological outcome in patients with spontaneous supratentorial, non-aneurysmal ICH Correspondence to.

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Learning objectives: Inability to swallow without aspiration is a common complication of acute stroke. In patients with prolonged swallowing dysfunction, a percutaneous endoscopic gastrostomy (PEG) tube is placed. Although PEG placement is an increasingly common practice, there is a paucity of and sometimes conflicting information about utility and clinical outcomes after PEGs. PEG complications can range from minor to major and complication rates range from 16-75%. For a better understanding of PEG complications versus recovery of swallowing a retrospective study was performed on acute stroke patients who had a failed swallow evaluation and had a PEG placed. Methods: A retrospective review was performed of all patients with acute ischemic and hemorrhagic stroke admitted to a large academic medical center who had a PEG placed after failing a swallowing study between January 2016 and March 2016. Complications reviewed included acute bleeding within 24 hours, chronic GI bleeding related to PEG, inadvertent dislodging of PEG, PEG infections and unexpected return to the operating room. Additionally, information about recovery of swallowing function was collected. Results: 64 patients were included. Average age was 70 years (SD 13.5). A PEG was placed on average 9.1 (SD 5.3) days into hospitalization and LOS averaged 7.6 days (SD 7.7) after PEG placement. The total number of patients who experienced a complication after PEG placement was 14 (21.9%). The most common complications were PEG infections, 6 patients (9.4%) and GI bleeding within 30 days of PEG placement, 6 patients (9.4%). There were 2 inadvertently pulled PEGs (3.1%) and 2 unexpected returns to the OR (3.1%). Out of the complications 2 (3.1%) resulted in death, 2 (3.1%) required surgical intervention. At least 20 patients recovered swallowing within a median of 26 days. At least 5 (7.8%) patients achieved recovery of swallow function within 14 days of PEG placement. Five patients had PEGs placed for inability to swallow liquids. Conclusions: In the acute stroke population, placement of PEG tubes was associated with a 21.9% complication rate and a 3.1% risk of mortality.