Causes and Outcome of Mechanical Ventilation in Patients With Hemispheric Ischemic Stroke
Section snippets
PATIENTS AND METHODS
Patients were selected from consecutive admissions to medical, neurologic, or neurosurgical intensive-care units at Saint Marys Hospital in Rochester, Minnesota, between 1976 and 1994. Only patients with a hemispheric ischemic stroke and subsequent intubation were included in this study. Patients with a posterior circulation stroke were excluded from analysis and are described in a separate report.5 We also excluded patients mechanically ventilated postoperatively in whom a stroke developed
RESULTS
From the Mayo Clinic medical records linkage system, we identified 24 patients with a clinical and CT scan diagnosis of an ischemic stroke who were intubated and mechanically ventilated after admission. The study group consisted of 11 women and 13 men (mean age, 68 years; range, 27 to 89). Thirteen patients had a right-sided cerebral infarct. In all patients, the initial or subsequent CT scan showed decreased attenuation in the territory of the middle cerebral artery. In 13 of 24 patients, an
DISCUSSION
The patient series compiled herein illustrates the circumstances surrounding tracheal intubation and mechanical ventilation in patients with acute hemispheric stroke. Our cohort of patients with ischemic hemispheric stroke who needed intubation and mechanical ventilation consisted solely of patients with ischemic stroke in the middle cerebral artery territory. In addition, a third of the patients had motor responses less than or equal to localization to pain stimulus, and early CT scan changes
CONCLUSION
Our study has important practical applications, although our patient series is too small to be used for accurate prognostication. The outcome in patients with a CT scan-documented stroke in the middle cerebral artery territory seems poor when brain swelling results in inability of patients to maintain an adequate airway, and mechanical ventilation is needed to secure adequate gas exchange. In only one patient, weaning was possible, but the neurologic deficit was devastating. Nevertheless,
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2017, Handbook of Clinical NeurologyCitation Excerpt :Mechanical ventilation in these early studies was almost invariably an unadjusted indicator of illness severity, and the key elements of its application were rarely described. Today, with increasingly effective medical and surgical therapies for cerebrovascular diseases, improved mechanical ventilation and general intensive care unit (ICU) practices, sophisticated techniques for the detection and prevention of secondary brain injury, and dedicated treatment in specialized neurological ICUs, the published long-term outcomes of mechanically ventilated neurocritical care patients have improved from survival rates of 29–36% (Steiner et al., 1997; Wijdicks and Scott, 1997; Berrouschot et al., 2000; Mayer et al., 2000) to 66% in a recent report (Steffling et al., 2012). Accurate prognostication can usually not be reliably performed in the early hours after presentation to the medical care system, so appropriate airway and respiratory management must be initiated to prevent secondary brain injury during the stabilization phase of care (Souter et al., 2015).
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2016, Clinics in Chest MedicineCitation Excerpt :In animal models, the use of high PEEP levels has been reported to be safe, but in humans with brain injury, the impact of PEEP on cerebral oxygenation and CPP is highly variable.61 It is uncommon to see changes in CPP or cerebral blood flow at PEEP levels less than 10 but it provides a rationale for recommending that monitoring of the CPP or central nervous system oxygen kinetics should be used in brain-injured patients requiring PEEP levels higher than 8 or 10 cm H2O.62,63 There are no specific guidelines for MV management in patients with severe stroke, whether ischemic or hemorrhagic.
Critical Care of the Patient with Acute Stroke
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2014, Journal of the Neurological SciencesCitation Excerpt :Mortality rates of 49% to 93% have been reported in various studies and outcome studies have also shown that most of the survivors are left with severe disability [4–12]. In view of high cost of intensive care units (ICUs) and reports of high mortality and morbidity [4–12], in ventilated patients, the cost effectiveness becomes an important issue [13], especially in places with limited resources. So, optimum utilization of health care resources is also required along with consideration of best interest of patients.
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