Acute ischemic stroke in the ICU: to admit or not to admit?

Abstract

Acute ischemic stroke (AIS) is an important health-care problem worldwide, and a significant cause of disability as well as mortality. The incidence of AIS is expected to increase in the future, because the majority of AIS are caused by cardio-embolic disorders and atherosclerosis, typical for the ageing population.Only two interventions in small subsets of patients have been demonstrated to improve the outcome of AIS patients. The single most important intervention to alter the natural history of AIS and improve the patients' functional outcome is the timely administration of a thrombolytic agent (intravenous rt-PA) in the appropriate patient within the narrow 4.5-h window [1]. Endovascular therapy represents an alternative therapy to intravenous rt-PA in those who are not candidates for intravenous rt-PA, but has no advantage over intravenous rt-PA [2]. Hemispheric decompression in patients less than 60 years of age with malignant middle cerebral artery territory (MCA) infarction and space-occupying brain oedema has been demonstrated to improve outcome. This result was confirmed in an individual patient meta-analysis, demonstrating a marked improvement in neurological recovery and survival [3]. For the age group older than 60 years of age with malignant MCA infarction, who are over-represented in the AIS patient group, the recently published DESTINY II trial was able to demonstrate that decompression was also able to reduce mortality, but not influence the proportion of patients with severe disability [4]. Despite initial promise, neuroprotective agents have failed to show a benefit in the management of AIS [5], as have tight glycaemic control [6], high dose albumin [7] and the use of anti-hypertensive agents [8,9].Today, increasing numbers of patients with AIS are admitted to an intensive care unit (ICU) for various indications. In this issue of Intensive Care Medicine, Kirkman et al. present a state of the art review of the ICU management of patients with AIS [10]. Their review is very thorough and provides key recommendations on the aforementioned interventions. Unfortunately, they were not able to provide much evidence-based guidance as to which patients should be admitted to the ICU, and which subgroups of AIS patients could actually benefit from ICU management. The guidelines of the Society of Critical Care Medicine state that ''in general ICUs should be reserved for those patents with reversible medical conditions who have a reasonable prospect of substantial recovery '' [11]. Inherent in this guideline as it applies to the AIS patient, is the assumption that the intensivist has an arsenal of therapeutic interventions which will alter the course of the patient's stroke and that these interventions will improve the patient's outcome. If we take a look at the data on mechanical ventilation in AIS patients, probably one of the main indications for referral to an ICU, not surprisingly, the requirement for mechanical ventilation in itself appears to be associated with both a higher short-and long-term mortal...

Outcomes of patients admitted to the ICU for acute stroke: a retrospective cohort

“…In addition to survival, functional outcomes are important to consider [ 35 , 36 ]. In a British study in 134 patients, only 13.7% had an mRS of 0–2 after 1 year [ 13 ].…”

Emergency Department as the Entry Point to Inpatient Care: A Nationwide, Population-Based Study in South Korea, 2016–2018

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Acute ischemic stroke in a university hospital intensive care unit: 1‐year costs and outcome

“…ECPS and ECPFO were calculated by dividing the total healthcare associated costs by the number of 1-year survivors and the number of patients with a favorable neurological outcome, respectively. The ECPS and ECPFO were also stratified by stroke severity using the NIHSS score into the following groups: no stroke or minor stroke (0-4), moderate stroke (5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15), moderate to severe stroke (16)(17)(18)(19)(20), and severe stroke (21-42).…”