(Stroke. 2001;32:1443-c.)
© 2001 American Heart Association, Inc.
Letters to the Editor |
Re: Cost and Outcome of Mechanical Ventilation for Life-Threatening Stroke
Department of Neurology, Hadassah University Hospital, Jerusalem, Israel
To the Editor:
We read with great interest the article by Mayer et al1 regarding the cost-effectiveness of artificial ventilation (AV) in patients with acute ischemic stroke. We have recently published a prospective study concerning prognostic factors in patients with stroke who needed AV.2 We included an unselected group of stroke patients admitted to our department. In agreement with the finding of Mayer et al1 and others,3 approximately 10% of our patients needed AV (16/162), and a low overall survival rate for patients who received AV (5/16, 31%) was noted. High scores on the National Institutes of Health Stroke Scale (NIHSS) on days 1 and 7 after the index stroke were identified as markers for the need of AV implementation. The day 7 NIHSS score was also the most powerful determinant of survival among ventilated patients (12.4±1.5 versus 19.5±4.2 for survivors versus nonsurvivors; P=0.003). Similarly to the report by Mayer et al,1 we also noted very poor outcome in patients who needed AV for neurological worsening. However, unlike in previous reports,1 4 we were able to identify a subgroup of ventilated stroke patients who had good outcomes. The survival rate of patients who needed AV for cardiopulmonary decompensation (CPD) was 40%. These patients were discharged with moderate disability (Glasgow Outcome Scale score of 2 to 3 and NIHSS score of 8.7), albeit after a prolonged hospitalization compared with nonventilated patients. Furthermore, their neurological status continued to improve with time, although it was still lower than in the patients who did not need AV at all. The good outcomes observed in these patients preclude conclusive statements regarding the grim prognosis of all patients with ischemic stroke who need AV.
In conclusion, while the prognosis of intubated stroke patients is guarded on the whole, the chances for good recovery of patients intubated for CPD during their acute stroke hospitalization are significantly better than those of patients intubated for neurological deterioration. The high costs of prolonged hospitalization in this subgroup of patients appears to be rewarding not only in extending life but also in preserving quality of life.
References
1.
Mayer SA,
Copeland D, Bernardini GL, Boden-Albala B, Lennihan L, Kossoff S, Sacco
RL. Cost and outcome of mechanical ventilation for life-threatening
stroke. Stroke. 2000;31:2346–2353.
2. Leker RR, Ben-Hur T. Prognostic factors in artificially ventilated stroke patients. J Neurol Sci. 2000;176:83–87.[Medline] [Order article via Infotrieve]
3.
Steiner T, Mendoza
G, De Georgia M, Schellinger P, Holle R, Hacke W. Prognosis of stroke
patients requiring mechanical ventilation in a neurological critical
care unit. Stroke. 1997;28:711–715.
4. Gujjar AR, Deibert E, Manno EM, Duff S, Diringer MN. Mechanical ventilation for ischemic stroke and intracerebral hemorrhage: indication, timing and outcome. Neurology.
Response
Division of Critical Care Neurology, Neurological Institute, New York, NY
We thank Drs Leker and Ben-Hur for their comments regarding our article. As we have pointed out, there is a need for more precise data regarding the prognosis of mechanically ventilated stroke patients. The more reliable these data are, the easier families may find it to forgo aggressive ICU care when it is unwanted and medically futile. In their small study of 16 ventilated stroke patients, Leker and Ben-Hur found that intubation for cardiopulmonary decompensation may be associated with a better prognosis than for neurological deterioration per se. This observation may be true, but it requires validation in a larger data set.
Evidence from our studyR1 and those of othersR2 R3 R4 R5 suggests that a low Glasgow Coma Scale score, loss of brain stem reflexes, and neurological deterioration after intubation are the most robust predictors of mortality among ventilated stroke patients. Certainly other factors may also be important, including the indication for intubation (as Leker and Ben-Hur suggest), demographic factors, comorbid conditions, and other interventions that have been applied. In our view, there is a need for a large database, similar to the APACHE system, for estimating prognosis for critically ill stroke patients. Because medicine is always evolving, the ideal approach might be to establish a multicenter, web-based stroke outcomes data bank to provide continuously updated prognostic information for patients, caregivers, and families who need the best information possible to make end-of-life decisions.
References
1. Mayer SA, Copeland DL, Bernardini GL, Boden-Albala B, Lennihan L, Kossoff S, Sacco RL. Cost and outcome of mechanical ventilation for life-threatening stroke. Stroke. 2000;31:2346–2353.
2.
Bushnell CD,
Phillips-Bute BG, Laskowitz DT, Lynch JR, Chilukuri V, Borel CO.
Survival and outcome after endotracheal intubation for stroke.
Neurology. 1999;52:1374–1381.
3. Burtin P, Bollaert PE, Feldmann L, Nace L, Lelarge P, Bauer P, Larcan A. Prognosis of stroke patients undergoing mechanical ventilation. Intensive Care Med. 1994;20:32–36.[Medline] [Order article via Infotrieve]
4.
Gujjar AR, Deibert
E, Manno EM, Duff S, Diringer MN. Mechanical ventilation for
ischemic stroke and intracerebral
hemorrhage: indications, timing, and outcome.
Neurology. 1998;51:447–451.
5. Steiner T, Mendoza G, De Georgia M, Schellinger P, Holle R, Hacke W. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke. 1997;28:711–715.
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