Normothermia and Stroke

Abstract

In the past two decades, there has been much focus on the adverse effect of fever on neurologic outcome, the benefits of hypothermia on functional outcomes, and the interplay of associated complications. Despite decades of experience regarding randomized, safety and feasibility, case-controlled, retrospective studies, there has yet to be a large, randomized, multicenter, clinical trial with the appropriate power to address the potential benefits of targeted temperature modulation compared to hypothermia alone. What remains unanswered is the appropriate timing of initiation, duration, rewarming speed, and depth of targeted temperature management. We learn from the cardiac arrest literature that there is a neuroprotective value to hypothermia and, most recently, near normothermia (36 °C) as well. We have also established that increased depths of cooling are associated with increases in shivering, which warrant more aggressive pharmacologic management. Normothermia also has the advantage of allowing for more rapid clearance of sedating medications and less confounding of neuroprognostication. More difficult to quantify is the increased nursing and patient care complexity associated with moderate hypothermia compared to normothermia. It remains crucial, for those patients who are being considered for hypothermia/normothermia, to be cared for in an experienced ICU, driven under protocol, with aggressive shivering management and an expectation and acceptance of the complications associated with targeted temperature management. If targeted temperature management is not of consideration, then aggressive fever control should be undertaken pharmacologically and non-invasively, as they have been shown to be safe.

Role of Decompressive Craniectomy in Ischemic Stroke

“…Although the benefit of hypothermia has been shown in patients with recent resuscitation and in children with peripartal hypoxia, its clinical usefulness in ischemic stroke patients is still uncertain (61–64). Given the fact that fever is associated with worse outcome, the maintenance of normothermia is generally recommended in patients with intracranial mass effect due to stroke (65). However, this is not supported by randomized controlled trials (66).…”

Zaburzenia termoregulacji pochodzenia ośrodkowego — jak diagnozować i leczyć

“…Moreover, there is no explicit answer to the question regarding temperature reductions in stroke patients; some issues are still unclear, i.e. the optimal moment of treatment institution, its duration, the rate of warming and the target temperature of cooling [52]. The AHA/ASA guidelines regarding ICH state only that hypothermia should be considered in ICH [46].…”

Implementation of Targeted Temperature Management in a Patient with Cerebral Arterial Gas Embolism

“…We believe that our treatment was better than TTM alone, because the treatment of choice for CAGE was HBOT. TTM is recommended in comatose adult patients with return of spontaneous circulation after cardiac arrest, but the role of induced hypothermia or TTM in acute ischemic stroke is controversial (Jauch et al , 2013 ; Marehbian and Greer, 2017 ). Our patient immediately underwent a single session of HBOT.…”

“…Targeted temperature management (TTM) is an established neuroprotective therapy for hypoxic/ischemic brain injury, particularly in patients after cardiac arrest (Callaway et al , 2015 ). However, the role of TTM in acute ischemic stroke is not clearly understood, despite ongoing feasibility and large clinical trials (Callaway et al , 2015 ; Marehbian and Greer, 2017 ). Furthermore, TTM is clinically used in various diseases such as traumatic brain injury, sepsis, cerebral air embolism, and acute carbon monoxide poisoning (Deng et al , 2003 ; Rim et al , 2012 ; Inoue et al , 2013 ; Perman et al , 2014 ; Oh et al , 2016 ).…”