Mechanical ventilation in patients with acute ischemic stroke: survival and outcome at one year

Abstract.

Objective: To assess the prognosis of patients with acute ischemic stroke who require mechanical ventilation and to determine early factors influencing mortality. Design: Prospective observational study. Setting: Medical intensive care unit with a cerebrovascular emergency unit in a university-affiliated hospital. Patients: Fifty-eight consecutive patients (mean age 65±13 years) requiring mechanical ventilation in the early course of an acute ischemic stroke. Measurements and results: Clinical data were recorded before intubation according to a standardized procedure. Mortality and functional outcome were assessed after a 1-year follow-up. Mechanical ventilation was started within 48 h after admission in 53 patients (91.4%). The mean duration of ventilation was similar in survivors (9.7±9.0 days) and non-survivors (8.6±8.7 days). Mortality was 72.4% at 1 year. Among the 16 survivors, none were in a persistent vegetative state and 11 had a Barthel index of 60, reflecting good functional status. Bilateral absence of corneal reflex and bilateral absence of pupillary light reflex had a positive predictive value of death of 1 (95% CI 0.78–1.00 and 0.74–1.00, respectively). After Cox regression analysis, presence of stupor or coma (OR 2.6, 95% CI 1.5–5.0), bilateral absence of corneal reflex before intubation (OR 3.4, 95% CI 1.4–8.7) and presence of ischemic cardiopathy (OR 2.8, 95% CI 1.4–5.5) were independent predictors of mortality. Conclusions: Systematic withholding of endotracheal intubation in patients with AIS is not recommended. Careful and rigorous neurologic examination, including assessment of brain stem reflexes, might help to identify patients with a very high probability of death despite mechanical ventilation.