Long-term Outcomes of Critically Ill Patients With Stroke Requiring Mechanical Ventilation

S100B and brain ultrasound: Novel predictors for functional outcome in acute ischemic stroke patients

OBJECTIVE

Stroke is a leading cause of mortality and disability worldwide. This study aimed to assess the prognostic value of serum S100B protein, transcranial color-coded duplex sonography (TCCD), and optic nerve sheath diameter (ONSD) in predicting functional outcomes in critically ill patients with acute ischemic stroke (AIS).

METHODS

In this prospective observational study, 80 adult AIS patients were evaluated. Serum S100B protein levels, ONSD, and middle cerebral artery pulsatility index (MCA PI) were measured on days 1 and 3. Functional outcomes at 90 days were assessed using the modified Rankin Scale (mRS) and categorized into favourable (mRS 0-2) or unfavourable (mRS 3-6) groups. The association of demographic, clinical, laboratory, and imaging parameters with mRS outcomes was analyzed.

RESULTS

Poor mRS outcomes occurred in 82.5 % of patients. Factors significantly associated with poor outcomes were female sex, higher National Institutes of Health Stroke Scale (NIHSS) scores on days 1, 3, and 7, and larger stroke size. Receiver Operating Characteristic (ROC) curve analysis revealed that ONSD at days 1 and 3, serum S100B levels at day 1, and right MCA PI at day 1 had significant predictive value for poor mRS outcome. Multivariate analysis identified female sex, S100B on day 1, and NIHSS on days 1, 3, and 7 as independent predictors of poor mRS outcomes.

CONCLUSIONS

The combination of S100B, ONSD, and MCA PI improved the prediction of functional outcomes in critically ill AIS patients. Early S100B measurement and brain ultrasound evaluation may serve as valuable prognostic tools for guiding therapeutic decision-making. This study provides novel insights into the role of S100B and brain ultrasound in stroke outcome prediction, particularly in critically ill AIS patients.

One-Year Outcomes in Patients With Acute Stroke Requiring Mechanical Ventilation

BACKGROUND

Long-term outcomes of patients with severe stroke remain poorly documented. We aimed to characterize one-year outcomes of patients with stroke requiring mechanical ventilation in the intensive care unit (ICU).

METHODS

We conducted a prospective multicenter cohort study in 33 ICUs in France (2017-2019) on patients with consecutive strokes requiring mechanical ventilation for at least 24 hours. Outcomes were collected via telephone interviews by an independent research assistant. The primary end point was poor functional outcome, defined by a modified Rankin Scale score of 4 to 6 at 1 year. Multivariable mixed models investigated variables associated with the primary end point. Secondary end points included quality of life, activities of daily living, and anxiety and depression in 1-year survivors.

RESULTS

Among the 364 patients included, 244 patients (66.5% [95% CI, 61.7%-71.3%]) had a poor functional outcome, including 190 deaths (52.2%). After adjustment for non-neurological organ failure, age ≥70 years (odds ratio [OR], 2.38 [95% CI, 1.26-4.49]), Charlson comorbidity index ≥2 (OR, 2.01 [95% CI, 1.16-3.49]), a score on the Glasgow Coma Scale <8 at ICU admission (OR, 3.43 [95% CI, 1.98-5.96]), stroke subtype (intracerebral hemorrhage: OR, 2.44 [95% CI, 1.29-4.63] versus ischemic stroke: OR, 2.06 [95% CI, 1.06-4.00] versus subarachnoid hemorrhage: reference) remained independently associated with poor functional outcome. In contrast, a time between stroke diagnosis and initiation of mechanical ventilation >1 day was protective (OR, 0.56 [95% CI, 0.33-0.94]). A sensitivity analysis conducted after exclusion of patients with early decisions of withholding/withdrawal of care yielded similar results. We observed persistent physical and psychological problems at 1 year in >50% of survivors.

CONCLUSIONS

In patients with severe stroke requiring mechanical ventilation, several ICU admission variables may inform caregivers, patients, and their families on post-ICU trajectories and functional outcomes. The burden of persistent sequelae at 1 year reinforces the need for a personalized, multi-disciplinary, prolonged follow-up of these patients after ICU discharge.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03335995.

Risk factors of mortality and severe disability in the patients with cerebrovascular diseases treated with perioperative mechanical ventilation

BACKGROUND

The prognosis of cerebrovascular diseases treated with mechanical ventilation during perioperative has not been clearly reported.

AIM

To analyze mortality and functional disability and to determine predictors of unfavorable outcome in the patients with cerebrovascular diseases treated with mechanical ventilation.

METHODS

A retrospective follow-up study of 111 cerebrovascular disease patients who underwent mechanical ventilation during the perioperative period in the First Hospital of Jilin University from June 2016 to June 2019 was performed. Main measurements were mortality and functional outcome in-hospital and after 3-month follow-up. According to the modified rankin scale (mRS), the functional outcome was divided into three groups: Good recovery (mRS ≤ 3), severe disability (mRS = 4 or 5) and death (mRS = 6). Univariate analysis was used to compare the differences between three functional outcomes. Multivariate logistic regression analysis was used to for risk factors of mortality and severe disability.

RESULTS

The average age of 111 patients was 56.46 ± 12.53 years, 59 (53.15%) were males. The mortality of in-hospital and 3-month follow-up were 36.9% and 45.0%, respectively. Of 71 discharged patients, 46.47% were seriously disabled and 12.67% died after three months follow-up. Univariate analysis showed that preoperative glasgow coma scale, operation start time and ventilation reasons had statistically significant differences in different functional outcomes. Multiple logistic regression analysis showed that the cause of ventilation was related to the death and poor prognosis of patients with cerebrovascular diseases. Compared with brainstem compression, the risk of death or severe disability of pulmonary disease, status epilepticus, impaired respiratory center function, and shock were 0.096 (95%CI: 0.028-0.328), 0.026 (95%CI: 0.004-0.163), 0.095 (95%CI: 0.013-0.709), 0.095 (95%CI: 0.020-0.444), respectively.

CONCLUSION

The survival rate and prognostic outcomes of patients with cerebrovascular diseases treated with mechanical ventilation during the perioperative period were poor. The reason for mechanical ventilation was a statistically significant predictor for mortality and severe disability.

Admission Glasgow Coma Scale Score as a Predictor of Outcome in Patients Without Traumatic Brain Injury

BACKGROUND

The Glasgow Coma Scale was developed in 1974 as an injury severity score to assess and predict outcome after traumatic brain injury. The tool is now used to score depth of impaired consciousness in patients with and without traumatic brain injury. However, evidence supporting the use of the Glasgow Coma Scale in the latter group is limited.

OBJECTIVE

To assess Glasgow Coma Scale score on hospital admission as a predictor of outcome in patients without traumatic brain injury.

METHODS

This was a secondary analysis of prospectively collected data from 3507 patients admitted to 4 hospitals between October 2015 and October 2019. Patients with a primary diagnosis of traumatic brain injury were excluded from this study.

RESULTS

The mean age of the 3507 participants in the study was 57 years. Participants were primarily female (52%), White (77%), and non-Hispanic (89%). On admission, 90% of patients had a modified Rankin Scale score of 0 to 3 and 72% had a Glasgow Coma Scale score of 13 to 15 (mild injury). Generalized estimating equation modeling indicated that admission Glasgow Coma Scale score did not predict modified Rankin Scale score at discharge in patients not diagnosed with traumatic brain injury (Glasgow Coma Scale score <8: z = -7.89, P < .001; Glasgow Coma Scale score 8-12: z = -4.17, P < .001).

CONCLUSIONS

The Glasgow Coma Scale is not recommended for use in patients without traumatic brain injury; clinicians should use a more appropriate and validated clinical assessment instrument for this patient population.

Lipopolysaccharide-induced sepsis-like state compromises post-ischemic neurological recovery, brain tissue survival and remodeling via mechanisms involving microvascular thrombosis and brain T cell infiltration

Sepsis predisposes for poor stroke outcome. This association suggests that sepsis disturbs post-ischemic tissue survival and brain remodeling. To elucidate this link, we herein exposed mice to 30 min intraluminal middle cerebral artery occlusion (MCAO) and induced a sepsis-like state at 72 h post-ischemia by intraperitoneal delivery of Escherichia coli lipopolysaccharide (LPS; three doses of 0.1 or 1 mg/kg, separated by 6 h), a major component of the bacterium's outer membrane. Neurological recovery, ischemic injury, brain remodeling and immune responses were evaluated over up to 56 days post-sepsis (dps) by behavioral tests, immunohistochemistry and flow cytometry. Delivery of 1 mg/kg but not 0.1 mg/kg LPS reduced rectal temperature over 48 h by up to 3.4 ± 3.1 °C, increased general and focal neurological deficits in the Clark score over 72 h and increased motor-coordination deficits in the tight rope test over up to 21 days. Notably, 1 mg/kg, but not 0.1 mg/kg LPS increased intercellular adhesion molecule-1 abundance on ischemic microvessels, increased microvascular thrombosis and increased patrolling monocyte and T cell infiltrates in ischemic brain tissue at 3 dps. Infarct volume was increased by 1 mg/kg, but not 0.1 mg/kg LPS at 3 dps (that is, 6 days post-MCAO), as was brain atrophy at 28 and 56 dps. Microglial activation in ischemic brain tissue, evaluated by morphology analysis of Iba-1 immunostainings, was transiently increased by 0.1 and 1 mg/kg LPS at 3 dps. Our data provide evidence that neurological recovery and brain remodeling are profoundly compromised in the ischemic brain post-sepsis as a consequence of cerebral thromboinflammation.