Outcome prediction in terms of functional disability and mortality at 1 year among ICU-admitted severe stroke patients: a prospective epidemiological study in the south of the European Union (Evascan Project, Andalusia, Spain)

Mortality, Functional Status, and Quality of Life after 5 Years of Patients Admitted to Critical Care for Spontaneous Intracerebral Hemorrhage

BACKGROUND

The objective of this study was to assess long-term outcome in patients with spontaneous intracerebral hemorrhage admitted to the intensive care unit.

METHODS

Mortality and Glasgow Outcome Scale, Barthel Index, and 5-level EQ-5D version (EQ-5D-5L) scores were analyzed in a multicenter cohort study of three Spanish hospitals (336 patients). Mortality was also analyzed in the Medical Information Mart for Intensive Care III (MIMIC-III) database.

RESULTS

The median (25th percentile-75th percentile) age was 62 (50-70) years, the median Glasgow Coma Score was 7 (4-11) points, and the median Acute Physiology and Chronic Health disease Classification System II (APACHE-II) score was 21 (15-26) points. Hospital mortality was 54.17%, mortality at 90 days was 56%, mortality at 1 year was 59.2%, and mortality at 5 years was 66.4%. In the Glasgow Outcome Scale, a normal or disabled self-sufficient situation was recorded in 21.5% of patients at 6 months, in 25.5% of patients after 1 year, and in 22.1% of patients after 5 years of follow-up (4.5% missing). The Barthel Index score of survivors improved over time: 50 (25-80) points at 6 months, 70 (35-95) points at 1 year, and 90 (40-100) points at 5 years (p < 0.001). Quality of life evaluated with the EQ-5D-5L at 1 year and 5 years indicated that greater than 50% of patients had no problems or slight problems in all items (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). In the MIMIC-III study (N = 1354), hospital mortality was 31.83% and was 40.5% at 90 days and 56.2% after 5 years.

CONCLUSIONS

In patients admitted to the intensive care unit with a diagnosis of nontraumatic intracerebral hemorrhage, hospital mortality up to 90 days after admission is very high. Between 90 days and 5 years after admission, mortality is not high. A large percentage of survivors presented a significant deficit in quality of life and functional status, although with progressive improvement over time. Five years after the hemorrhagic stroke, a survival of 30% was observed, with a good functional status seen in 20% of patients who had been admitted to the hospital.

Development of a predictive nomogram for 28-day mortality risk in non-traumatic or post-traumatic subarachnoid hemorrhage patients

OBJECTIVE

Subarachnoid hemorrhage (SAH) is associated with high rates of mortality and permanent disability. At present, there are few definite clinical tools to predict prognosis in SAH patients. The current study aims to develop and assess a predictive nomogram model for estimating the 28-day mortality risk in both non-traumatic or post-traumatic SAH patients.

METHODS

The MIMIC-III database was searched to select patients with SAH based on ICD-9 codes. Patients were separated into non-traumatic and post-traumatic SAH groups. Using LASSO regression analysis, we identified independent risk factors associated with 28-day mortality and incorporated them into nomogram models. The performance of each nomogram was assessed by calculating various metrics, including the area under the curve (AUC), net reclassification improvement (NRI), integrated discrimination improvement (IDI), and decision curve analysis (DCA).

RESULTS

The study included 999 patients with SAH, with 631 in the non-traumatic group and 368 in the post-traumatic group. Logistic regression analysis revealed critical independent risk factors for 28-day mortality in non-traumatic SAH patients, including gender, age, glucose, platelet, sodium, BUN, WBC, PTT, urine output, SpO2, and heart rate and age, glucose, PTT, urine output, and body temperature for post-traumatic SAH patients. The prognostic nomograms outperformed the commonly used SAPSII and APSIII systems, as evidenced by superior AUC, NRI, IDI, and DCA results.

CONCLUSION

The study identified independent risk factors associated with the 28-day mortality risk and developed predictive nomogram models for both non-traumatic and post-traumatic SAH patients. The nomogram holds promise in guiding prognosis improvement strategies for patients with SAH.

Predictors and Temporal Trends of Withdrawal of Life-Sustaining Therapy After Acute Stroke in the Florida Stroke Registry

Temporal trends and factors associated with the withdrawal of life-sustaining therapy (WLST) after acute stroke are not well determined.

DESIGN

Observational study (2008-2021).

SETTING

Florida Stroke Registry (152 hospitals).

PATIENTS

Acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Importance plots were performed to generate the most predictive factors of WLST. Area under the curve (AUC) for the receiver operating curve were generated for the performance of logistic regression (LR) and random forest (RF) models. Regression analysis was applied to evaluate temporal trends. Among 309,393 AIS patients, 47,485 ICH patients, and 16,694 SAH patients; 9%, 28%, and 19% subsequently had WLST. Patients who had WLST were older (77 vs 70 yr), more women (57% vs 49%), White (76% vs 67%), with greater stroke severity on the National Institutes of Health Stroke Scale greater than or equal to 5 (29% vs 19%), more likely hospitalized in comprehensive stroke centers (52% vs 44%), had Medicare insurance (53% vs 44%), and more likely to have impaired level of consciousness (38% vs 12%). Most predictors associated with the decision to WLST in AIS were age, stroke severity, region, insurance status, center type, race, and level of consciousness (RF AUC of 0.93 and LR AUC of 0.85). Predictors in ICH included age, impaired level of consciousness, region, race, insurance status, center type, and prestroke ambulation status (RF AUC of 0.76 and LR AUC of 0.71). Factors in SAH included age, impaired level of consciousness, region, insurance status, race, and stroke center type (RF AUC of 0.82 and LR AUC of 0.72). Despite a decrease in the rates of early WLST (< 2 d) and mortality, the overall rates of WLST remained stable.

CONCLUSIONS

In acute hospitalized stroke patients in Florida, factors other than brain injury alone contribute to the decision to WLST. Potential predictors not measured in this study include education, culture, faith and beliefs, and patient/family and physician preferences. The overall rates of WLST have not changed in the last 2 decades.

Patterns and Outcomes of Intensive Care on Acute Ischemic Stroke Patients in the US

BACKGROUND

Up to 20% of acute ischemic stroke (AIS) patients may benefit from intensive care unit (ICU)-level care; however, there are few studies evaluating ICU availability for AIS. We aim to summarize the proportion of elderly AIS patients in the United States who are admitted to an ICU and assess the national availability of ICU-level care in AIS.

METHODS

We performed a retrospective cohort study using de-identified Medicare inpatient datasets from January 1, 2016 through December 31, 2019 for US individuals aged ≥65 years. We used validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify AIS admission and interventions. ICU-level care was identified by revenue center code. AIS patient characteristics and interventions were stratified by receipt of ICU-level care, comparing differences through calculated standardized mean difference score due to large sample sizes.

RESULTS

From 2016 through 2019, a total of 952 400 admissions by 850 055 individuals met criteria for hospital admission for AIS with 19.9% involving ICU-level care. Individuals were predominantly >75 years of age (58.5%) and identified as white (80.0%). Hospitals on average admitted 11.4% (SD 14.6) of AIS patients to the ICU, with the median hospital admitting 7.7% of AIS patients to the ICU. The ICU admissions were younger and more likely to receive reperfusion therapy but had more comorbid conditions and neurologic complications. Of the 5084 hospitals included, 1971 (38.8%) reported no ICU-level AIS care. Teaching hospitals (36.9% versus 1.6%, P<0.0001) with larger AIS volume (P<0.0001) or in larger metropolitan areas (P<0.0001) were more likely to have an ICU available.

CONCLUSIONS

We found evidence of national variation in the availability of ICU-level care for AIS admissions. Since ICUs may provide comprehensive care for the most severe AIS patients, continued effort is needed to examine ICU accessibility and utility among AIS.

Lactate-to-albumin ratio is associated with in-hospital mortality in patients with spontaneous subarachnoid hemorrhage and a nomogram model construction

Introduction

Subarachnoid hemorrhage (SAH) is a severe hemorrhagic stroke with high mortality. However, there is a lack of clinical tools for predicting in-hospital mortality in clinical practice. LAR is a novel clinical marker that has demonstrated prognostic significance in a variety of diseases.

Methods

Critically ill patients diagnosed and SAH with their data in the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database and the eICU Collaborative Research Database (eICU-CRD) were included in our study. Multivariate logistic regression was utilized to establish the nomogram.

Results

A total of 244 patients with spontaneous SAH in the MIMIC-IV database were eligible for the study as a training set, and 83 patients in eICU-CRD were included for external validation. Data on clinical characteristics, laboratory parameters and outcomes were collected. Univariate and multivariate logistic regression analysis identified age (OR: 1.042, P-value: 0.003), LAR (OR: 2.592, P-value: 0.011), anion gap (OR: 1.134, P-value: 0.036) and APSIII (OR: 1.028, P-value: < 0.001) as independent predictors of in-hospital mortality and we developed a nomogram model based on these factors. The nomogram model incorporated with LAR, APSIII, age and anion gap demonstrated great discrimination and clinical utility both in the training set (accuracy: 77.5%, AUC: 0.811) and validation set (accuracy: 75.9%, AUC: 0.822).

Conclusion

LAR is closely associated with increased in-hospital mortality of patients with spontaneous SAH, which could serve as a novel clinical marker. The nomogram model combined with LAR, APSIII, age, and anion gap presents good predictive performance and clinical practicability.

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

Background

Although acute stroke is a leading cause of morbidity and mortality worldwide, data on outcomes of stroke patients requiring ICU admission are limited. We aimed to identify factors associated with a good neurological outcome (defined as a modified Rankin Scale score [mRS] of 0–2) 6 months after ICU admission.

Methods

We retrospectively studied consecutive patients who were admitted to the ICU of a French university-affiliated hospital between January 2014 and December 2018 and whose ICD-10 code indicated acute stroke. Patients with isolated subarachnoid hemorrhage or posttraumatic stroke were excluded.

Results

The 323 identified patients had a median age of 67 [54.5–77] years; 173 (53.6%) were male. The main reasons for ICU admission were neurological failure (87%), hemodynamic instability (28.2%), acute respiratory failure (26%), and cardiac arrest (5.3%). At ICU admission, the Glasgow Coma Scale score was 6 [4–10] and the SAPSII was 54 [35–64]. The stroke was hemorrhagic in 248 (76.8%) patients and ischemic in 75 (23.2%). Mechanical ventilation was required in 257 patients (79.6%). Six months after ICU admission, 61 (19.5%) patients had a good neurological outcome (mRS, 0–2), 50 (16%) had significant disability (mRS, 3–5), and 202 (64.5%) had died; 10 were lost to follow-up. By multivariable analysis, factors independently associated with not having an mRS of 0–2 at 6 months were older age (odds ratio, 0.93/year; 95% confidence interval, 0.89–0.96; P < 0.01) and lower Glasgow Coma Scale score at ICU admission (odds ratio, 1.23/point; 95% confidence interval, 1.07–1.40; P < 0.01).

Conclusions

Acute stroke requiring ICU admission carried a poor prognosis, with less than a fifth of patients having a good neurological outcome at 6 months. Age and depth of coma independently predicted the outcome.

Serum S100B correlates with health-related quality of life and functional outcome in patients at 1 year after aneurysmal subarachnoid haemorrhage

Background

Early, objective prognostication after aneurysmal subarachnoid haemorrhage (aSAH) is difficult. A biochemical marker would be desirable. Correlation has been found between levels of the protein S100 beta (S100B) and outcome after aSAH. Timing and clinical usefulness are under investigation.

Methods

Eighty-nine patients admitted within 48 h of aSAH were included. Modified ranking scale (mRS), EuroQoL health-related quality of life measure (EQ-5D_index) and EuroQoL visual analogue scale (EQ-VAS) values were evaluated after 1 year. S100B was measured in blood samples collected at admission and up to day 10.

Results

S100B correlated significantly with EQ-5D_index and mRS, but not EQ-VAS at 1 year after aSAH. A receiver operating characteristic analysis for peak S100B values (area under the curve 0.898, 95% confidence interval 0.828–0.968, p < 0.0001), with a cutoff of 0.4 μg/l, yielded 95.3% specificity and 68% sensitivity for predicting unfavourable outcome. Dichotomized S100B (> 0.4 μg/l vs ≤ 0.4 μg/l), age and Hunt and Hess grading scale score (HH) were associated with unfavourable mRS outcome in univariate logistic regression analysis. Dichotomized S100B was the only variable independently correlated with unfavourable mRS outcome in a multivariate logistic regression analysis.

Conclusions

For the first time, S100B was shown to correlate with mRS and health-related quality of life at 1 year after aSAH. Peak S100B can be used as a prognostic factor for unfavourable outcome measured as dichotomized mRS after aSAH. A peak value cutoff of 0.4 μg/l is suggested. Ethical approval no: 2013/366-31, 4th of February 2014.

Is Conservative Treatment Better than Surgical Treatment for Basal Ganglia Hemorrhage in a Conventionally Non-Surgical Indication Group with Poor Motor Function?

Background: The treatment options for basal ganglia intracerebral hemorrhage (ICH), either surgical or conservative, remain controversial. A previous study developed "A new modified ICH (MICH) score" that suggests which treatment option will be better for basal ganglia ICH. According to this scoring system, a MICH score of 0 or 1 indicates that conservative treatment is better than surgical treatment. The purpose of this study was to determine whether conservative treatment is still a better option for a basal ganglia hemorrhage in patients with MICH scores of 0 and 1, with initial poor motor grades. Methods: This retrospective study was comprised of 41 patients with a spontaneous basal ganglia hemorrhage. These patient groups had no previous brain lesions, their initial MICH score was 0 or 1, and the manual muscle test (MMT) of their hand was grade 2+ or lower in the initial evaluation. All patients were transferred to the Department of Rehabilitation Medicine and received rehabilitation treatment. Ten patients had an operative intervention, which was burr-hole aspiration or craniotomy with hematoma removal. The control group included 31 patients who underwent conservative treatment. Outcome evaluations used the Berg Balance Scale (BBS), Modified Barthel Index (MBI), and Brunnstrom recovery stage (BRS) which were evaluated at initial and regular follow-ups after 1, 3, and 6 months. We defined an improvement state if the BRS of their hand became 4 or more in 6 months, which means an escape from the synergic pattern. Results: Demographic characteristics showed no significant differences in age, sex, hemiplegic side, initial GCS score, presence of IVH and hydrocephalus, or distribution of MICH scores 0 and 1. There was only a significant difference in the distribution of hematoma volume between groups of less than 20 mL and groups from 21 to 50 mL (p = 0.049). There were no significant differences in MBI values in 1 month or improvement of BRS of their hand in 6 months between the two groups. Conclusions: Even in the group classified as predominantly conservative in basal ganglia hemorrhage patients, if the initial muscle strength is low, it is necessary to reconsider whether conservative treatment is superior to surgical treatment in terms of functional improvement.

Association of Acute Alteration of Consciousness in Patients With Acute Ischemic Stroke With Outcomes and Early Withdrawal of Care

BACKGROUND AND OBJECTIVES

Early consciousness disorder (ECD) after acute ischemic stroke (AIS) is understudied. ECD may influence outcomes and the decision to withhold or withdraw life-sustaining treatment.

METHODS

We studied patients with AIS from 2010 to 2019 across 122 hospitals participating in the Florida Stroke Registry. We studied the effect of ECD on in-hospital mortality, withholding or withdrawal of life-sustaining treatment (WLST), ambulation status on discharge, hospital length of stay, and discharge disposition.

RESULTS

Of 238,989 patients with AIS, 32,861 (14%) had ECD at stroke presentation. Overall, average age was 72 years (Q1 61, Q3 82), 49% were women, 63% were White, 18% were Black, and 14% were Hispanic. Compared to patients without ECD, patients with ECD were older (77 vs 72 years), were more often female (54% vs 48%), had more comorbidities, had greater stroke severity as assessed by the National Institutes of Health Stroke Scale (score ≥5 49% vs 27%), had higher WLST rates (21% vs 6%), and had greater in-hospital mortality (9% vs 3%). Using adjusted models accounting for basic characteristics, patients with ECD had greater in-hospital mortality (odds ratio [OR] 2.23, 95% CI 1.98-2.51), had longer hospitalization (OR 1.37, 95% CI 1.33-1.44), were less likely to be discharged home or to rehabilitation (OR 0.54, 95% CI 0.52-0.57), and were less likely to ambulate independently (OR 0.61, 95% CI 0.57-0.64). WLST significantly mediated the effect of ECD on mortality (mediation effect 265; 95% CI 217-314). In temporal trend analysis, we found a significant decrease in early WLST (<2 days) (R² 0.7, p = 0.002) and an increase in late WLST (≥2 days) (R² 0.7, p = 0.004).

DISCUSSION

In this large prospective multicenter stroke registry, patients with AIS presenting with ECD had greater mortality and worse discharge outcomes. Mortality was largely influenced by the WLST decision.

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

Background and purpose

Little is currently known about the cost‐effectiveness of intensive care of acute ischemic stroke (AIS). We evaluated 1‐year costs and outcome for patients with AIS treated in the intensive care unit (ICU).

Materials and methods

A single‐center retrospective study of patients admitted to an academic ICU with AIS between 2003 and 2013. True healthcare expenditure was obtained up to 1 year after admission and adjusted to consumer price index of 2019. Patient outcome was 12‐month functional outcome and mortality. We used multivariate logistic regression analysis to identify independent predictors of favorable outcomes and linear regression analysis to assess factors associated with costs. We calculated the effective cost per survivor (ECPS) and effective cost per favorable outcome (ECPFO).

Results

The study population comprised 154 patients. Reasons for ICU admission were: decreased consciousness level (47%) and need for respiratory support (40%). There were 68 (44%) 1 year survivors, of which 27 (18%) had a favorable outcome. High age (odds ratio [OR] 0.95, 95% confidence interval [CI] 0.91–0.98) and high hospital admission National Institutes of Health Stroke Scale score (OR 0.92, 95% CI 0.87–0.97) were independent predictors of poor outcomes. Increased age had a cost ratio of 0.98 (95% CI 0.97–0.99) per added year. The ECPS and ECPFO were 115,628€ and 291,210€, respectively.

Conclusions

Treatment of AIS in the ICU is resource‐intense, and in an era predating mechanical thrombectomy the outcome is often poor, suggesting a need for further research into cost‐efficacy of ICU care for AIS patients.

Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness

BACKGROUND AND PURPOSE

Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST).

METHODS

Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition.

RESULTS

Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], P<0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], P<0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], P<0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate.

CONCLUSIONS

In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.

Long-Term Mortality Among ICU Patients With Stroke Compared With Other Critically Ill Patients

OBJECTIVES

Assessment of all-cause mortality of intracerebral hemorrhage and ischemic stroke patients admitted to the ICU and comparison to the mortality of other critically ill ICU patients classified into six other diagnostic subgroups and the general Dutch population.

DESIGN

Observational cohort study.

SETTING

All ICUs participating in the Dutch National Intensive Care Evaluation database.

PATIENTS

All adult patients admitted to these ICUs between 2010 and 2015; patients were followed until February 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of all 370,386 included ICU patients, 7,046 (1.9%) were stroke patients, 4,072 with ischemic stroke, and 2,974 with intracerebral hemorrhage. Short-term mortality in ICU-admitted stroke patients was high with 30 days mortality of 31% in ischemic stroke and 42% in intracerebral hemorrhage. In the longer term, the survival curve gradient among ischemic stroke and intracerebral hemorrhage patients stabilized. The gradual alteration of mortality risk after ICU admission was assessed using left-truncation with increasing minimum survival period. ICU-admitted stroke patients who survive the first 30 days after suffering from a stroke had a favorable subsequent survival compared with other diseases necessitating ICU admission such as patients admitted due to sepsis or severe community-acquired pneumonia. After having survived the first 3 months after ICU admission, multivariable Cox regression analyses showed that case-mix adjusted hazard ratios during the follow-up period of up to 3 years were lower in ischemic stroke compared with sepsis (adjusted hazard ratio, 1.21; 95% CI, 1.06-1.36) and severe community-acquired pneumonia (adjusted hazard ratio, 1.57; 95% CI, 1.39-1.77) and in intracerebral hemorrhage patients compared with these groups (adjusted hazard ratio, 1.14; 95% CI, 0.98-1.33 and adjusted hazard ratio, 1.49; 95% CI, 1.28-1.73).

CONCLUSIONS

Stroke patients who need intensive care treatment have a high short-term mortality risk, but this alters favorably with increasing duration of survival time after ICU admission in patients with both ischemic stroke and intracerebral hemorrhage, especially compared with other populations of critically ill patients such as sepsis or severe community-acquired pneumonia patients.

Survival and predictors of mortality among patients admitted to the intensive care units in southern Ethiopia: A multi-center cohort study

BACKGROUND

The burden of life-threatening conditions requiring intensive care units has grown substantially in low-income countries related to an emerging pandemic, urbanization, and hospital expansion. The rate of ICU mortality varied from region to region in Ethiopia. However, the body of evidence on ICU mortality and its predictors is uncertain. This study was designed to investigate the pattern of disease and predictors of mortality in Southern Ethiopia.

METHODS

After obtaining ethical clearance from the Institutional Review Board (IRB), a multi-center cohort study was conducted among three teaching referral hospital ICUs in Ethiopia from June 2018 to May 2020. Five hundred and seventeen Adult ICU patients were selected. Data were entered in Statistical Package for Social Sciences version 22 and STATA version 16 for analysis. Descriptive statistics were run to see the overall distribution of the variables. Chi-square test and odds ratio were determined to identify the association between independent and dependent variables. Multivariate analysis was conducted to control possible confounders and identify independent predictors of ICU mortality.

RESULTS

The mean (±SD) of the patients admitted in ICU was 34.25(±5.25). The overall ICU mortality rate was 46.8%. The study identified different independent predictors of mortality. Patients with cardiac arrest were approximately 12 times more likely to die as compared to those who didn't, AOR = 11.9(95% CI:6.1 to 23.2).

CONCLUSION

The overall mortality rate in ICU was very high as compared to other studies in Ethiopia as well as globally which entails a rigorous activity from different stakeholders.

Clinical outcomes and prognostic factors for prolonged mechanical ventilation in patients with acute stroke and brain trauma

BACKGROUND/PURPOSE

Neurological dysfunction is a common condition necessitating prolonged mechanical ventilation (PMV). We investigated the clinical features and outcomes of patients with acute neurological diseases requiring PMV.

METHODS

This retrospective observational study was conducted at the Respiratory Care Center (RCC) of Chang Gung Memorial Hospital, Taiwan, between January 2011 and January 2014. The main outcome was weaning success, defined as successful withdrawal from mechanical ventilator support for more than 5 days.

RESULTS

The study included 103 patients with acute stroke and brain trauma receiving PMV. Weaning success was reported in 63 (61%) patients and weaning failure was reported in 40 (39%) patients. Patients in the weaning failure group were older and had a lower RCC Glasgow Coma Scale (GCS) score (6.0 vs 7.9, p = 0.005), lower albumin level (2.8 vs 3.1, p = 0.015), longer RCC stay (28.7 vs 21.3 days, p = 0.017), and higher in-hospital mortality rate (47% vs 9%, p < 0.01). Multivariate analysis revealed that reduced RCC GCS score is an independent prognostic factor for weaning failure (odds ratio [OR] = 1.22, 95% confidence interval [CI] = 1.05-1.46, p = 0.016) and that per unit increase of RCC GCS score is associated with a lower risk of in-hospital mortality (OR = 0.83, 95% CI = 0.70-0.96, p = 0.019).

CONCLUSION

Reduced RCC GCS score is an independent prognostic factor for weaning failure, and is associated with increased in-hospital mortality rates in patients with acute stroke and brain trauma requiring PMV.

Association between critical care admission and 6-month functional outcome after spontaneous intracerebral haemorrhage

BACKGROUND

There is uncertainty about the clinical benefit of admission to critical care after spontaneous intracerebral haemorrhage (ICH).

PURPOSE

We investigated factors associated with critical care admission after spontaneous ICH and evaluated associations between critical care and 6-month functional outcome.

METHODS

We included 825 patients with acute spontaneous non-traumatic ICH, recruited to a prospective multicenter observational study. We evaluated the characteristics associated with critical care admission and poor 6-month functional outcome (modified Rankin Scale, mRS > 3) using univariable (chi-square test and Wilcoxon rank-sum test, as appropriate) and multivariable analysis.

RESULTS

286 patients (38.2%) had poor 6-month functional outcome. Seventy-seven (9.3%) patients were admitted to critical care. Patients admitted to critical care were younger (p < 0.001), had lower GCS score (p < 0.001), larger ICH volume (p < 0.001), more often had intraventricular extension (p = 0.008) and underwent neurosurgery (p < 0.001). Critical care admission was associated with poor functional outcome at 6 months (39/77 [50.7%] vs 286/748 [38.2%]; p = 0.034); adjusted OR 2.43 [95%CI 1.36-4.35], p = 0.003), but not with death (OR 1.29 [95%CI 0.71-2.35; p = 0.4). In ordinal logistic regression, patients admitted to critical care showed an OR 1.47 (95% CI 0.98-2.20; p = 0.07) for a shift in the 6-month modified Rankin Scale.

CONCLUSIONS

Admission to critical care is associated with poor 6-month functional outcome after spontaneous ICH but not with death. Patients admitted to critical care were a priori more severely affected. Although adjusted for main known predictors of poor outcome, our findings could still be confounded by unmeasured factors. Establishing the true effectiveness of critical care after ICH requires a randomised trial with clinical outcomes and quality of life assessments.

Glasgow Coma Scale Score Fluctuations are Inversely Associated With a NIRS-based Index of Cerebral Autoregulation in Acutely Comatose Patients

BACKGROUND

The Glasgow Coma Scale (GCS) is an essential coma scale in critical care for determining the neurological status of patients and for estimating their long-term prognosis. Similarly, cerebral autoregulation (CA) monitoring has shown to be an accurate technique for predicting clinical outcomes. However, little is known about the relationship between CA measurements and GCS scores among neurological critically ill patients. This study aimed to explore the association between noninvasive CA multimodal monitoring measurements and GCS scores.

METHODS

Acutely comatose patients with a variety of neurological injuries admitted to a neurocritical care unit were monitored using near-infrared spectroscopy-based multimodal monitoring for up to 72 hours. Regional cerebral oxygen saturation (rScO2), cerebral oximetry index (COx), GCS, and GCS motor data were measured hourly. COx was calculated as a Pearson correlation coefficient between low-frequency changes in rScO2 and mean arterial pressure. Mixed random effects models with random intercept was used to determine the relationship between hourly near-infrared spectroscopy-based measurements and GCS or GCS motor scores.

RESULTS

A total of 871 observations (h) were analyzed from 57 patients with a variety of neurological conditions. Mean age was 58.7±14.2 years and the male to female ratio was 1:1.3. After adjusting for hemoglobin and partial pressure of carbon dioxide in arterial blood, COx was inversely associated with GCS (β=-1.12, 95% confidence interval [CI], -1.94 to -0.31, P=0.007) and GCS motor score (β=-1.06, 95% CI, -2.10 to -0.04, P=0.04). In contrast rScO2 was not associated with GCS (β=-0.002, 95% CI, -0.01 to 0.01, P=0.76) or GCS motor score (β=-0.001, 95% CI, -0.01 to 0.01, P=0.84).

CONCLUSIONS

This study showed that fluctuations in GCS scores are inversely associated with fluctuations in COx; as COx increases (impaired autoregulation), more severe neurological impairment is observed. However, the difference in COx between high and low GCS is small and warrants further studies investigating this association. CA multimodal monitoring with COx may have the potential to be used as a surrogate of neurological status when the neurological examination is not reliable (ie, sedation and paralytic drug administration).

Clinical Predictors of Survival and Functional Outcome of Stroke Patients Admitted to Critical Care

OBJECTIVES

To determine the predictive value of commonly used clinical variables upon ICU admission for long-term all-cause mortality and functional outcome of adult stroke patients admitted to the ICU.

DESIGN

Retrospective observational cohort study.

SETTING

General and neurosurgical ICUs of the University College London Hospitals in North Central London.

PATIENTS

All adult ICU patients with a clinical diagnosis of acute stroke admitted between February 2010 and May 2012.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographic and clinical data concerning the first 24 hours after ICU admission were obtained. Patients were followed until February 2016 to assess long-term survival. Functional outcome was determined using the modified Rankin Scale. We evaluated 131 critically ill stroke patients, with a median (interquartile range) age of 70 years (55-78 yr). One-year mortality rate was 52.7%. Surviving patients were followed up over a median (interquartile range) period of 4.3 years (4.0-4.8 yr). The multivariable model that best predicted long-term all-cause mortality indicated that mortality of critically ill stroke patients was predicted by high Acute Physiology and Chronic Health Evaluation II score, impaired consciousness (Glasgow Coma Scale score ≤ 8) as reason for ICU admission, low Glasgow Coma Scale sum score after 24 hours, and absence of brainstem reflexes. Long-term independent functional status occurred in 30.9% of surviving patients and was predicted by low Acute Physiology and Chronic Health Evaluation II score, high Glasgow Coma Scale sum score at ICU admission, and absence of mass effect on CT scan.

CONCLUSIONS

Mortality in critically ill stroke patients is high and occurs most often shortly after the event. Less than one in three surviving patients is able to function independently after 1 year. This study has identified several clinical variables that predict long-term all-cause mortality and functional outcome among critically ill stroke patients and found that mainly acute physiologic disturbance and absolute values of neurologic clinical assessment are predictive.

Spontaneous Intracerebral Hemorrhage

Background and Purpose- We compared clinical and radiological predictors of long-term mortality in patients with spontaneous intracerebral hemorrhage (ICH) needing intensive care. Methods- A retrospective multicenter study of adult ICH patients treated in Finnish tertiary hospital's intensive care units during 2003 to 2013. We created 3 multivariable models (clinical, radiological, and combined clinical-radiological) for 12-month mortality prediction and compared their areas under receiver operating characteristic curves (AUCs). We analyzed supratentorial and infratentorial ICHs separately. Results- Of 972 patients (796 supratentorial ICH, 176 infratentorial ICH) included, 43% died within 12 months (42% supratentorial ICH, 49% infratentorial ICH). For all patients, the clinical model (AUC, 0.83; 95% CI, 0.81-0.86) outperformed the radiological model (AUC, 0.73; 95% CI, 0.70-0.77; P<0.001), yet the combined model (AUC, 0.85; 95% CI, 0.83-0.88) outperformed both condensed models (P<0.001). For supratentorial ICH, the combined model outperformed both the clinical and radiological models (AUC, 0.84; 95% CI, 0.81-0.87 versus AUC, 0.82; 95% CI, 0.79-0.85 and AUC, 0.73; 95% CI, 0.69-0.77; P<0.001 for all). For infratentorial ICH patients, the combined model significantly outperformed the radiological model but not the clinical model (AUC, 0.92; 95% CI, 0.88-0.96 versus AUC, 0.76; 95% CI, 0.69-0.83 versus AUC, 0.91; 95% CI, 0.87-0.95; P<0.001 and P=0.433, respectively). Conclusions- Clinical factors were more important than objective radiological factors for 12-month mortality prediction in intensive care unit-treated ICH patients. The effect of clinical and radiological factors on outcome was different for supratentorial and infratentorial ICHs stressing that these should not be treated as one entity.

Acute Posterior Cranial Fossa Hemorrhage-Is Surgical Decompression Better than Expectant Medical Management?

Background

To compare the in-hospital mortality and institutional morbidity from medical therapy (MT), external ventricular drainage (EVD) and suboccipital decompressive craniectomy (SDC) following an acute hemorrhagic posterior cranial fossa stroke (PCFH) in patients admitted to the neurosciences critical care unit (NCCU). Retrospective observational single-center cohort study in a tertiary care center. All consecutive patients (n = 104) admitted with PCFH from January 1st 2005–December 31st 2011 were included in the study.

Methods

All patients with a PCFH were identified and confirmed by reviewing computed tomography of the brain reported by a specialist neuroradiologist. Management decisions (MT, EVD, and SDC) were identified from operative notes and electronic patient records.

Results

Following a PCFH, 47.8 % (n = 11) patients died after EVD placement without decompression, 45.7 % (n = 16) died following MT alone, and 17.4 % (n = 8) died following SDC. SDC was associated with lower mortality compared to MT with or without EVD (χ² test p = 0.006, p = 0.008). Age, ICNARC score, brain stem involvement, and hematoma volume did not differ significantly between the groups. There was a statistically significant increase in hydrocephalus and intraventricular bleeds in patients treated with EVD placement and SDC (χ² test p = 0.02). Median admission Glasgow Coma Scale scores for the MT only, MT with EVD, and SDC groups were 8, 6, and 7, respectively (ranges 3–15, 3–11 and 3–13) and did not differ significantly (Friedman test: p = 0.89). SDC resulted in a longer NCCU stay (mean of 17.4 days, standard deviation = 15.4, p < 0.001) and increased incidence of tracheostomy (50 vs. 17.2 %, p = 0.0004) compared to MT with or without EVD.

Conclusions

SDC following PCFH was associated with a reduction in mortality compared to expectant MT with or without EVD insertion. A high-quality multicenter randomized control trial is required to evaluate the superiority of SDC for PCFH.

Risk Factors for Multiple Organ Dysfunction Syndrome in Severe Stroke Patients

Background

Severe stroke patients have poor clinical outcome which may be associated with development of multiple organ dysfunction syndrome (MODS). Therefore, the aim of our study was to investigate independent risk factors for development of MODS in severe stroke patients.

Methods

Ninety seven severe stroke patients were prospective recruited from Jan 2011 to Jun 2015. The development of MODS was identified by Sequential Organ Failure Assessment (SOFA) score (score ≥ 3, at least two organs), which was assessed on day 1, 4, 7, 10 and 14 after admission. Baseline characteristics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, Glasgow coma score (GCS) and cerebral imaging parameters were collected at admission. Cox regression was performed to determine predictors for the development of MODS. Medical complications after admission and in-hospital mortality were also investigated.

Results

33 (34%) patients were in MODS group and 64 (66%) were in non-MODS group within 14 days after admission. Patients in MODS group had more smoker (51.5% vs 28.1%, p = 0.023), higher NIHSS score (23.48 ± 6.12 vs 19.81 ± 4.83, p = 0.004), higher APACHE II score (18.70 ± 5.18 vs 15.64 ± 4.36, p = 0.003) and lower GCS score (6.33 ± 2.48 vs 8.14 ± 2.73, p = 0.002). They also had higher rate of infarction in multi vascular territories (36.4% vs 10.9%, p = 0.003). The most common complication in all patients was pulmonary infection, while complication scores were comparable between two groups. Patients with MODS had higher in-hospital mortality (69.7% vs 9.4%, p = 0.000). In Cox regression, NIHSS score (RR = 1.084, 95% CI 1.019–1.153) and infarction in multi vascular territories (RR = 2.345 95% CI 1.105–4.978) were independent risk factors for development of MODS.

Conclusions

In acute phase of stroke, NIHSS score and infarction in multi vascular territories predicted MODS in severe stroke patients. Moreover, patients with MODS had higher in-hospital mortality, suggesting that early identification of MODS is critical important.

Impact of electrolyte imbalances on the outcome of aneurysmal subarachnoid hemorrhage: A prospective study

Background:

Electrolyte disturbances are frequently observed during the acute and subacute period after subarachnoid hemorrhage (SAH) and may potentially worsen therapeutic outcome. This study was conducted to determine the pattern of electrolyte disturbance in the acute and subacute phase after SAH and their effect on the long-term outcome of the patients.

Materials and Methods:

Fifty-three patients were prospectively enrolled. The standards of care for all patients were uniformly performed. The serum levels of electrolytes (sodium, potassium and magnesium) were determined with measurements obtained on admission, 3–5 and 7–10 days after SAH. Radiographic intensity of hemorrhage (Fisher's scale), and the clinical grading (World Federation of Neurosurgical Societies grade) were documented in the first visit. The outcomes were evaluated using Glasgow outcome scale at 3 months after discharge.

Results:

Hyponatremia was the most common electrolyte imbalance among the patients but did not worsen the outcome. Although less common, hypernatremia in the subacute phase was significantly associated with poor outcome. Both hypokalemia and hypomagnesemia were predictive of poor outcomes.

Conclusions:

Because electrolyte abnormalities can adversely affect the outcome, the serum levels of electrolytes should be closely monitored with serial measurements and treated properly in patients with aneurysmal SAH.

Outcome of Intensive Care Unit-Dependent, Tracheotomized Patients with Cerebrovascular Diseases

BACKGROUND

Outcome studies in intensive care unit -dependent, tracheotomized, and mechanical ventilated patients with cerebrovascular disease (CVD) are scarce.

METHODS

In a retrospective approach, we analyzed the outcome of 143 patients with ischemic stroke (IS), primary intracerebral hemorrhage (PICH), and subarachnoid hemorrhage (SAH). To measure the potential benefit of in-patient rehabilitation, we used the Functional Independence Measure (FIM). In addition, weaning and rehabilitation duration, duration of mechanical ventilation (MV) in the acute care hospital (preweaning), and mortality rates were assessed.

RESULTS

Approximately 50% of all patients were transferred home. These patients were fully independent or under nursing support. We found no differences regarding weaning and rehabilitation durations, or FIM scores in between each entity. Log-regression analyses showed that every day on MV generates a 3.2% reduction of the possibility to achieve a beneficial outcome (FIM ≥ 50 points [only moderate assistance necessary]), whereas every day in-patient rehabilitation without MV increases the chance for favorable outcome by 1.9%. Mortality rates were 5% for IS and 10% for PICH and SAH, respectively.

CONCLUSIONS

This study shows that even severely affected, tracheotomized patients with CVD benefit from early in-patient rehabilitation, irrespective of the etiology of vascular brain injury. Mortality rates of early rehabilitation in CVD are low. Until no validated outcome predictors are available, all efforts should be undertaken to enable in-patient rehabilitation, even in severe cases of CVD to improve outcome and to prevent accommodation in long-time-care facilities.

Gait and Glasgow Coma Scale scores can predict functional recovery in patients with traumatic brain injury

Fifty-one patients with mild (n = 14), moderate (n = 10) and severe traumatic brain injury (n = 27) received early rehabilitation. Level of consciousness was evaluated using the Glasgow Coma Score. Functional level was determined using the Glasgow Outcome Score, whilst mobility was evaluated using the Mobility Scale for Acute Stroke. Activities of daily living were assessed using the Barthel Index. Following Bobath neurodevelopmental therapy, the level of consciousness was significantly improved in patients with moderate and severe traumatic brain injury, but was not greatly influenced in patients with mild traumatic brain injury. Mobility and functional level were significantly improved in patients with mild, moderate and severe traumatic brain injury. Gait recovery was more obvious in patients with mild traumatic brain injury than in patients with moderate and severe traumatic brain injury. Activities of daily living showed an improvement but this was insignificant except for patients with severe traumatic brain injury. Nevertheless, complete recovery was not acquired at discharge. Multiple regression analysis showed that gait and Glasgow Coma Scale scores can be considered predictors of functional outcomes following traumatic brain injury.

Benefits of early tracheostomy in ventilated stroke patients? Current evidence and study protocol of the randomized pilot trial SETPOINT (Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial)

RATIONALE

Ventilated intensive care patients with ischemic or hemorrhagic strokes have a poor prognosis. Early tracheostomy has led to advantages in selected groups of non-cerebrovascular intensive care patients, including shorter ventilation time, shorter intensive care unit length of stay, and reduced complications. It is completely unclear whether ventilated stroke patients might benefit from early tracheostomy, too.

AIM

Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial (SETPOINT) is a pilot trial aiming to investigate the safety, feasibility, and potential benefits of early tracheostomy vs. prolonged intubation (and possibly late tracheostomy) in patients with severe ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. The primary objective is to compare early tracheostomy and prolonged intubation with respect to the intensive care unit - length of stay and the time until the start of rehabilitation in these patients.

DESIGN

SETPOINT is a prospective, randomized, controlled, outcome observer-blinded, monocenter trial. Patients with severe ischemic stroke, intracerebral or subarachnoid hemorrhage requiring intubation and ventilation are eligible. After passing predefined criteria, enrolled patients are randomized to either percutaneous tracheostomy within the first three-days from intubation or to weaning/extubation attempts or percutaneous tracheostomy between days 7 and 14 from intubation (n = 30 per group).

STUDY OUTCOMES

The primary end-point is the intensive care unit length of stay. Secondary end-points are functional outcome and mortality at discharge and after six-months, duration to transferability, duration of ventilation, duration and quality of weaning from respirator, need of analgesia and sedation, procedure-related complications, frequency of pneumonia and sepsis, and costs of treatment.

DISCUSSION

To clarify the potential benefit of early tracheostomy in critical care ventilated stroke patients, a randomized multicenter trial in a larger patient population is clearly needed. If this monocentric pilot gives promising safety, feasibility, and benefit results, such a multicenter trial will be planned. The results will have a relevant direct impact on the critical care of stroke.

Risk factors for 1-year mortality in patients with nontraumatic intracranial hemorrhage requiring intensive care

BACKGROUND

Mortality in patients with intracranial hemorrhage remains high. The aim of this study was to determine the 1-year survival and potential risk factors for 1-year mortality in patients with nontraumatic intracranial hemorrhage requiring intensive care.

METHODS

This was a 3-year (2005-2007) retrospective study in a university-level intensive care unit (ICU). Patient characteristics, level of consciousness, and radiological findings of the primary head computed tomography were recorded on admission. Sequential Organ Failure Assessment scores were recorded during the ICU stay. Patients were divided into two groups: subarachnoid hemorrhage (SAH) group and intracerebral hemorrhage (ICH) group. Kaplan-Meier survival curves were constructed, and independent risk factors were determined using Cox proportional hazards regression analyses.

RESULTS

Two hundred twenty-nine patients were analyzed. The 1-year mortality rate was 32% in patients with SAH and 44% in patients with ICH. The risk factors for 1-year mortality in both groups were unconsciousness on admission [SAH: hazard ratio (HR) 6.2, P = 0.017 and ICH: HR 3.0, P = 0.004] and renal failure during the ICU stay (SAH: HR 2.5, P = 0.021 and ICH: HR 3.6, P = 0.021). Risk factors specific to the type of hemorrhage were the presence of ICH (HR 2.0, P = 0.033) and diffuse cerebral edema (HR 2.3, P = 0.017) in the SAH group and a prior use of warfarin (HR 5.1, P = 0.016) in the ICH group.

CONCLUSIONS

In addition to decreased level of consciousness on admission, renal failure during the ICU stay is an independent risk factor for 1-year mortality in nontraumatic SAH as well as ICH.

Changes in the acute functional and cognitive disability states of severe hemorrhagic stroke patients

The purpose of this study was to characterize temporal patterns of functional and cognitive disability changes during the acute period in hemorrhagic stroke patients. The study subjects were 62 hemorrhagic stroke patients admitted to a surgical intensive care unit at a university hospital located in Incheon, South Korea. As outcome variables, functional disability, cognitive ability, and employment status were evaluated directly at 1, 3, and 6 months after admission. The results showed that significant improvements in functional and cognitive ability were observed between 1 and 6 months after admission. In terms of functional disability, subjects considered their overall functional ability (dependence on others) to be less recovered than the specific functional abilities (feeding, grooming, or toileting): 75% of the subjects stated that they were completely independent on others, whereas 92.9%, 83.9%, and 83.9% of subjects indicated that they were completely independent for feeding, grooming, and toileting at the 6-month assessments, respectively. In terms of cognitive ability, attention, communication, and memory recovery rates were found to be relatively good. However, the proportion of subjects that achieved complete problem solving and safety and social behavior recovery were lower than those that achieved attention, communication, and memory recovery. Our findings can provide the empirical evidences when neuroscience nurses use educational and supportive strategies for rehabilitation of hemorrhagic stroke patients.

Long-term survival in older critically ill patients with acute ischemic stroke

OBJECTIVES

To compare survival in older patients with acute ischemic stroke admitted to intensive care units (ICUs) with those not requiring ICU care and to assess the impact of mechanical ventilation (MV) and percutaneous gastrostomy tubes (PEG) on long-term mortality.

DESIGN

Multicentered retrospective cohort study.

SETTING

Administrative data from the Centers for Medicare and Medicaid Services covering 93 metropolitan counties primarily in the eastern half of the United States.

PATIENTS

31,301 patients discharged with acute ischemic stroke in 2000.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Mortality from the time of index hospitalization up to the end of the follow-up period of 12 months. Information was also gathered on use of mechanical ventilation, percutaneous gastrostomy, sociodemographic variables and a host of comorbid conditions. Of all patients with acute ischemic stroke, 26% required ICU admission. The crude death rate for ICU stroke patients was 21% at 30 days and 40% at 1-yr follow-up. At 30 days, after adjustment of sociodemographic variables and comorbidities, ICU patients had a 29% higher mortality hazard compared with non-ICU patients. MV was associated with a five-fold higher mortality hazard (hazard ratio 5.59, confidence interval [CI] 4.93-6.34). The use of PEG was not associated with mortality at 30 days. By contrast, at 1-yr follow up in 30-day survivors, ICU admission was not associated with mortality hazard (hazard ratio 1.01, 95% CI 0.93-1.09). MV still had a higher risk of death (hazard ratio 1.88, 95% CI 1.57-2.25), and PEG patients had a 2.59-fold greater mortality hazard (95% CI 2.38-2.82).

CONCLUSIONS

Both short-term and long-term mortality in older patients with acute ischemic stroke admitted to ICUs is lower than previously reported. The need for MV and PEG are markers for poor long-term outcome. Future research should focus on the identification of clinical factors that lead to increased mortality in long-term survivors and efforts to reduce those risks.

Predicting hospital mortality using APACHE II scores in neurocritically ill patients: a prospective study

Four versions of Acute Physiology and Chronic Health Evaluation are limited in predicting hospital mortality for neurocritically ill patients. This prospective study aimed to develop and assess the accuracy of a modified APACHE II model in predicting mortality in neurologic intensive care unit (N-ICU). A total of 653 patients entered the study. APACHE II scores on admission, and worst 24-, 48-, and 72-h scores were obtained. Neurologic diagnoses on admission were classified into five categories: cerebral infarction, intracranial hemorrhage, neurologic infection, neuromuscular disease, and other neurologic diseases. We developed a modified APACHE II model based on the variables of the 72-h APACHE II score and disease category using a multivariate logistic regression procedure to estimate probability of death. We assessed the calibration and discrimination of the modified APACHE II model using the Hosmer-Lemeshow goodness-of-fit chi-squared statistic and area under the receiver operating characteristic curve (AU-ROC). The modified APACHE II model had good discrimination (AU-ROC = 0.88) and calibration (Hosmer-Lemeshow statistic: chi (2) = 3.707, P = 0.834). The discrimination of the 72-h APACHE II score for cerebral infarction, intracerebral hemorrhage, and neurologic infection was satisfactory, with AU-ROC of 0.858, 0.863, and 1.000, respectively, but it was poor in discriminating for the categories of other neurologic diseases and neuromuscular disease. The results showed that our modified APACHE II model can accurately predict hospital mortality for patients in N-ICU. It is more applicable to clinical practice than the previous model because of its simplicity and ease of use.

Prediction of the survival and functional ability of severe stroke patients after ICU therapeutic intervention

BACKGROUND

This study evaluated the benefits and impact of ICU therapeutic interventions on the survival and functional ability of severe cerebrovascular accident (CVA) patients.

METHODS

Sixty-two ICU patients suffering from severe ischemic/haemorrhagic stroke were evaluated for CVA severity using APACHE II and the Glasgow coma scale (GCS). Survival was determined using Kaplan-Meier survival tables and survival prediction factors were determined by Cox multivariate analysis. Functional ability was assessed using the stroke impact scale (SIS-16) and Karnofsky score. Risk factors, life support techniques and neurosurgical interventions were recorded. One year post-CVA dependency was investigated using multivariate analysis based on linear regression.

RESULTS

The study cohort constituted 6% of all CVA (37.8% haemorrhagic/62.2% ischemic) admissions. Patient mean(SD) age was 65.8(12.3) years with a 1:1 male: female ratio. During the study period 16 patients had died within the ICU and seven in the year following hospital release. The mean(SD) APACHE II score at hospital admission was 14.9(6.0) and ICU mean duration of stay was 11.2(15.4) days. Mechanical ventilation was required in 37.1% of cases. Risk ratios were; GCS at admission 0.8(0.14), (p = 0.024), APACHE II 1.11(0.11), (p = 0.05) and duration of mechanical ventilation 1.07(0.07), (p = 0.046). Linear coefficients were: type of CVA - haemorrhagic versus ischemic: -18.95(4.58) (p = 0.007), GCS at hospital admission: -6.83(1.08), (p = 0.001), and duration of hospital stay -0.38(0.14), (p = 0.40).

CONCLUSION

To ensure a better prognosis CVA patients require ICU therapeutic interventions. However, as we have shown, where tests can determine the worst affected patients with a poor vital and functional outcome should treatment be withheld?

Cryptogenic stroke in a patient with a PFO: a decision analysis

BACKGROUND

Octogenarian Israeli prime-minister Ariel Sharon recently sustained a mild, reversible stroke. A patent foramen ovale (PFO) was detected and anticoagulants were given pending PFO closure. A few days later, he sustained major intracerebral hemorrhage and has since remained in vegetative state. The events triggered serious criticism in the mass media, experts promoting one management option over others. Because knowledge of outcome and hindsight bias evaluation of appropriateness of care, we sought to systematically review the clinical case.

METHODS

We performed a formal decision analysis to identify the preferred management between anticoagulation, antiplatelets, PFO closure, or no treatment. Using the best evidence available, we built a decision tree.

MAIN OUTCOMES

recurrent stroke and treatment complications within 1 year.

RESULTS

Optimal decision was found to be critically sensitive to assumptions about etiology, efficacy and safety of treatments, recurrence risk, and to small changes in utilities. In multiway sensitivity analysis, when the risk of recurrent stroke was <0.12 per year, no treatment was the best management. PFO closure is dominant only when the risk of recurrent stroke is >0.12 per year closure effectiveness is assumed to be <0.28. When closure effectiveness is >0.6, it is inferior to anticoagulation and antiplatelet management.

CONCLUSIONS

Uncertainties precluded a clear-cut answer and choice was found to be a "toss-up," often associated with much controversy. Use of novel therapies, such as PFO closure, outside clinical trials will not reduce uncertainty about efficacy.

Impact of infection on length of intensive care unit stay after intracerebral hemorrhage

INTRODUCTION

The vast majority of patients with intracerebral hemorrhage (ICH) are admitted to an intensive care unit (ICU). Patients admitted to ICUs have a high risk of developing nosocomial infections, while complicating infection appears to be associated with a longer ICU stay. An increased length of ICU stay translates directly into increased costs. The aim of this study was to assess the impact of a complicating infection on the length of ICU stay in patients with ICH.

METHODS

We studied 148 consecutive patients who were admitted to the ICU and diagnosed with spontaneous ICH. Complicating infection was defined as when a patient was treated with antibiotics for the diagnosis of an infectious disease after admission. The impacts of clinical factors on the length of ICU stay were assessed, including complicating infection, sex, age, Glasgow Coma Scale (GCS) score at admission, and surgical intervention.

RESULTS

The median ICU stay was 8 days (interquartile range, 3-18 days). Complicating infection occurred in 75 patients (51%). A multiple regression model for predicting the length of ICU stay was performed. After controlling for sex, age, GCS score, and surgical intervention, complicating infection was significantly associated with a longer ICU stay (P < 0.001). Surgical intervention was also an independent predictor (P < 0.001). The length of the ICU stay was significantly longer for patients with GCS scores of 6-8, compared to those with GCS scores of 13-15 (P = 0.01).

CONCLUSIONS

Complicating infection was an independent predictor of a prolonged ICU stay in patients with ICH.

[Survival of comatose stroke victims in a neurological department in Dakar]

BACKGROUND

In Dakar, stroke is the most frequent neurological disease with the highest mortality. Victims may present in a critical state of coma. The objective of this study was to evaluate survival among comatose stroke patients in Dakar, Senegal.

METHODS

This was a longitudinal prospective study from April 2006 to July 2007 conducted in the Neurological Intensive Care Unit (NICU) of Fann University Teaching Hospital in Senegal. Were included in the study, all stroke patients confirmed by CT scan with a Glasgow coma score less than or equal to 8/15. Patients with subarachnoid hemorrhage were excluded.

RESULTS

A total of 105 patients were evaluated with 54 cases of ischemic stroke among them. The mean age was 61.87+/-14.16 years. The mean duration of hospital stay in the NICU was 10.82+/-11 days with an estimated mortality of 82.9%; the three-month survival was 9.52%. The median overall survival was 7+/-1 days (CI(95%): 5-9).

CONCLUSION

Comatose stroke patients have a poor prognosis, emphasizing the crucial importance of primary prevention.

Predictors of survival and functional outcome in acute stroke patients admitted to the stroke intensive care unit

Multivariate models have not been widely used to predict the outcome of acute stroke patients admitted to the intensive care unit (ICU). The purpose of this study was to determine potential measures observed in the first 12 h post-stroke that predict early mortality and functional outcomes in ICU-admitted stroke patients. Eight hundred and fifty acute stroke patients (ischemic stroke, 508; intracerebral hemorrhage, 342) were included in this analysis between November 2002 and December 2006. Measures of interest were obtained in the first 12 h after onset of stroke were analyzed for three types of outcome: 3-month mortality, 3-month mortality or institutional care, and poor functional outcomes at discharge. Poor functional outcomes were defined as a Barthel index <80 or a Rankin scale >2. Multivariate regression models were used to determine the predictive value of the observed measures. After 3 months, 17% of patients had died; 21% were alive but being cared for in institutional settings; and 62% were alive and living at home. Functional status at discharge indicated 16% of patients had died, poor function in 50%, and good function in 34% of patients. Initial stroke severity, measured by National Institute of Health Stroke Scale, and dependence on a ventilator predicts 3-month mortality and poor outcome in all stroke patients. In addition, old age, previous stroke, and total anterior circulatory infarct were associated with poor outcome in ischemic stroke patients; old age, low body mass index and the presence of intraventricular hemorrhage were associated with poor outcomes in intracerebral hemorrhage patients. In conclusion, early stroke mortality and outcome at discharge can be predicted in the first few hours following an acute stroke for moderate to severe ICU-admitted stroke patients.

[Prognostic capacity of brain herniation signs in patients with structural neurological injury]

OBJECTIVE

To determine whether the usual mortality prediction systems (APACHE and SAPS) can be complemented by cranial computed tomography (CT) brain herniation findings in patients with structural neurological involvement.

DESIGN

Prospective cohort study.

SETTING

Trauma ICU in university hospital.

PATIENTS

One hundred and fifty five patients admitted to ICU in 2003 with cranial trauma or acute stroke.

MAIN VARIABLES OF INTEREST

Data were collected on age, diagnosis, mortality, admission cranial CT findings and on APACHE II, APACHE III and SAPS II scores.

RESULTS

Mean age was 47.8 +/- 19.4 years; APACHE II, 17.1 +/- 7.2 points; SAPS II, 43.7 +/- 17.7 points; and APACHE III, 55.8 +/- 29.7 points. Hospital mortality was 36% and mortality predicted by SAPS II was 38%, by APACHE II 30% and by APACHE III 36%. The 56 non-survivors showed greater midline shift on cranial CT scan versus survivors (4.2 +/- 5.5 vs. 1.6 +/- 3.22 mm, p = 0.002) and higher severity as assessed by SAPS II, APACHE II and APACHE III. The mortality rate was significantly higher in patients with subfalcial herniation (61% vs. 30%, p < 0.001). In the multivariate logistic regression analysis, hospital mortality was associated with the likelihood of death according to APACHE III (OR 1.07; 95% CI: 1.05-1.09) and with presence of subfalcial herniation (OR 3.15; 95% CI: 1.07-9.25).

CONCLUSIONS

In critical care patients with structural neurological involvement, cranial CT signs of subfalcial herniation complement the prognostic information given by the usual severity indexes.

Survival and long-term functional outcome in 1,155 consecutive neurocritical care patients*

OBJECTIVE

To analyze survival, mortality, and long-term functional disability outcome and to determine predictors of unfavorable outcome in critically ill patients admitted to a neurologic intensive care unit (neuro-ICU).

DESIGN

Retrospective cohort study with post-neuro-ICU health-related evaluation of functional long-term outcome.

SETTING

Ten-bed neuro-ICU in a tertiary care university hospital.

PATIENTS

A consecutive cohort of 1,155 patients admitted to a neuro-ICU during a 36-month period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 1,155 consecutive patients, of whom 41% were women, were enrolled in the study. The predominant reasons for neuro-ICU care were cerebrovascular diseases, such as intracerebral hemorrhage (20%), subarachnoid hemorrhage (16%), and complicated, malignant ischemic stroke (15%). A total of 213 patients (18%) died in the neuro-ICU. The Glasgow Outcome Scale and modified Rankin scale were dichotomized into two groups determining unfavorable vs. favorable outcome (Glasgow Outcome Scale scores 1-3 vs. 4-5 and modified Rankin scale scores 2-6 vs. 0-1). Factors associated with unfavorable outcome in the unselected cohort according to logistic regression analysis were admission diagnosis, age (p < .01), and a higher score in the simplified Therapeutic Intervention Scoring System (TISS-28) at time of admission (p < .01). Functional long-term outcome was evaluated by telephone interview for 662 patients after a median follow-up of approximately 2.5 yrs by evaluating modified Rankin scale and Glasgow Outcome Scale scores. Factors associated with unfavorable functional long-term outcome were admission diagnosis, sex, age of >70 yrs (odds ratio, 8.45; 95% confidence interval, 4.52-15.83; p < .01), TISS-28 of >40 points at admission (odds ratio, 4.05; 95% confidence interval, 2.54-6.44; p < .01), TISS-28 of >40 points at discharge from the neuro-ICU (odds ratio, 3.50; 95% confidence interval, 1.51-8.09; p < .01), and length of stay (odds ratio, 1.01; 95% confidence interval, 1.00-1.03; p = .02).

CONCLUSION

We found admission diagnosis, age, length of stay, and TISS-28 scores at admission and discharge to be independent predictors of unfavorable long-term outcome in an unselected neurocritical care population.

The societal costs of intracerebral hemorrhage in Spain

This study estimates the lifetime societal costs associated with incident intracerebral hemorrhage (ICH) in Spain. An epidemiological model of ICH incidence, survival and morbidity was developed using retrospective data from 28 hospitals in Andalusia and published data identified in a systematic literature review. Data on resource utilization and costs were obtained from five hospitals in the Canary Islands, whereas cost of outpatient care, informal care and lost productivity were obtained from standardized questionnaires completed by survivors of ICH. The lifetime societal costs of incident ICH in Spain is estimated at 46,193 euros per patient. Direct medical costs accounted for 32.7% of lifetime costs, whilst 67.3% were related to indirect costs. One-third of direct medical costs over the first year were attributable to follow-up care, including rehabilitation. Indirect costs were dominated by costs of informal care (71.2%). The aggregated lifetime societal costs for the estimated 12,534 Spanish patients with a first-ever ICH in 2004 was 579 million euros. ICH implies substantial costs to society primarily due to formal and informal follow-up care and support needed after hospital discharge. Interventions that offer survival benefits without improving patients' functional status are likely to further increase the societal costs of ICH.

Mortality prediction in critical care for acute stroke: Severity of illness-score or coma-scale?

BACKGROUND AND PURPOSE

The use of early prognostic data provided by various scores in critically ill stroke patients remains unclear. We tested the performance of the Simplified Acute Physiology Score (SAPS) II in prediction of mortality of acute stroke patients in the NeuroCriticalCareUnit (NCCU).

METHODS

During one year every patient admitted to the NCCUs at 2 University hospitals for cerebral ischemia (CI) or intracerebral hemorrhage (ICH) and intubated was included in this study. Data for SAPS (I)/II and the Glasgow Coma Scale (GCS) were collected, and mortality at 10 days, 90 days and 1 year was determined. Prognostic performance of all scores was tested by calculation of receiver operating curve (ROC) and by Cox regression analysis.

RESULTS

90 patients were included in the study, 49 with ICH and 41 with CI. Mortality after 10 days was 32.2%, after 3 months 58.9% and after 1 year 67.8%. Compared by their area under curve the predictive values were overall quite good for both SAPS (I) (0.77) and SAPS II (0.77) as well as GCS. Motor subscore was equal to total GCS (0.75 vs. 0.73). In Cox regression models all three scores were independent predictors of fatal outcome.

CONCLUSION

SAPS II and SAPS (I) but also the GCS are valuable tools for prediction of short and long-term mortality in acute stroke patients treated in NCCU. The GCS as a predictor for mortality in stroke patients could be further simplified by using its subscore "best motor response" alone.

Hospital discharge to care facility: a patient-centered outcome for the evaluation of intensive care for octogenarians

INTRODUCTION

Hospital survival and length of stay are commonly used for the evaluation of intensive care outcome for the young and octogenarian patients (>/= 80 years old).

HYPOTHESIS

Hospital discharge to a care facility should be considered for more accurate evaluation of intensive care outcome, especially for octogenarian patients.

DESIGN

An observational descriptive study.

PATIENTS

A total of 6,154 consecutive hospital admissions requiring intensive care over 4 years.

MEASUREMENTS

Demographics, preadmission comorbidities, severity of illness, acute hospital diagnosis categories, charges and destination after discharge, and postdischarge survival for up to 42 months.

RESULTS

Octogenarians represented 15% of intensive care admissions (900 admissions). The interventions performed in the ICU, the severity of illness measured by sequential organ failure assessment (SOFA), and hospital length of stay were similar for octogenarian and younger patients. Octogenarians had higher hospital mortality (10% vs 6%, p < 0.01) and discharge to care facility (35% vs 18%, p < 0.01) than younger patients. The average hospital charge per octogenarian hospital survivor discharged to home was $128,000, compared to $100,000 for a younger hospital survivor. At follow-up, octogenarian hospital survivors who were discharged to a care facility had higher mortality than hospital survivors discharged to home (31% vs 17%, p < 0.01). On multiple logistic regression, older age, female gender, preadmission comorbidities, type of admission, SOFA score >/= 4, mechanical ventilation >/= 96 h, requirement for tracheotomy, and hospital diagnosis categories were independent factors for discharge of hospital survivors to a care facility.

CONCLUSIONS

Hospital survival and length of stay did not accurately measure intensive care outcome for octogenarians. Care dependency among octogenarians who survived intensive care was prevalent and decreased their long-term survival. Care dependency and functional disability among hospital survivors should be considered for more accurate evaluation of intensive care outcome in that age group.