Early Extubation Tied to Better Outcome After Stroke Thrombectomy

Pauline Anderson

May 29, 2020

The shorter, the better when it comes to time spent on a ventilator for stroke patients who undergo mechanical thrombectomy, new research suggests.

A study of more than 400 patients showed that those who were extubated within 6 hours were more than twice as likely to have a better outcome than those extubated later. Also for these patients, the rate of developing pneumonia was lower.

Dr Simon Fandler-Höfler

These findings are important because data regarding ventilation time for stroke patients are "scarce," investigator Simon Fandler-Höfler, MD, Department of Neurology, Medical University of Graz, Austria, told Medscape Medical News.

"Our results indicate that patients with an anterior circulation occlusion, which account for 85% to 95% of all thrombectomies, should be extubated as early as safely possible," Fandler-Höfler said.

The findings were presented at the Congress of the European Academy of Neurology (EAN) 2020, which was being held online because of the COVID-19 pandemic.

Favorable Outcomes

The study included 441 consecutive adult patients (mean age, 69 years) who underwent mechanical thrombectomy under general anesthesia as treatment for an anterior circulation large-vessel occlusion stroke. The patients were evenly matched with regard to sex.

The researchers categorized the participants into those who were extubated within 6 hours (early extubation) after thrombectomy, those extubated within 6 to 24 hours after (delayed extubation), and those extubated after more than 24 hours (late extubation).

The primary outcome was a favorable Modified Rankin Scale (mRS) score of 0–2 three months post stroke.

Although the median ventilation time was 3 hours, individually, it ranged widely from 1 to 530 hours. More than half of the patients (57.7%) were extubated early; 27.7% were in the delayed group, and 14.5% were in the late group.

Results showed that 42.6% of patients had a favorable outcome.

When analyzed as a continuous variable, ventilation time strongly correlated with mRS scores at 3 months (P < .001).

Significant predictors of adverse outcomes included age (P < .001), hypertension (P < .001), chronic heart disease (P = .02), diabetes mellitus (P = .002), atrial fibrillation (P = .001), and National Institutes of Health Stroke Scale (NIHSS) score at admission (P < .001).

Patients who underwent successful recanalization also had significantly better outcomes.

Of those extubated early, about three quarters had a good outcome; fewer than half (45%) had bad outcomes, Fandler-Höfler reported.

"We found that those patients with early extubation had significantly better outcomes," he said, compared with those whose extubation was delayed (odds ratio [OR], 2.4; 95% confidence interval [CI], 1.53 – 3.76; P < .001).

Impact on Clinical Practice?

Early pneumonia within the stroke unit or neurointensive care unit was strongly associated with ventilation time. For the patients in the early group, the rate of pneumonia was only 9.6%, compared with 20.6% for the delayed group.

Fandler-Höfler found the results for those who received less ventilation "surprising" and said the results could have an impact on clinical practice.

Chronic heart disease and pneumonia were more prevalent in the late group than in the other groups. Also, for the patients in the late group, NIHSS scores were significantly higher at admission, and successful recanalization was less frequent.

For with regard to mRS scores at 3 months, participants who underwent ventilation the longest "really had very bad outcomes," Fandler-Höfler said. The mortality rate for those patients was more than 50%.

He acknowledged that "it was no surprise that patients who were intubated for several days had worse outcomes."

The researchers also examined the reasons why some patients were extubated later than others. Stroke complications, including brain edema, insufficient alertness, seizures, and respiratory insufficiency, played a role.

Admission Delays

Delayed extubation was also strongly associated with admission "outside of core working hours," when fewer doctors and nurses were available, Fandler-Höfler said.

Within core hours, almost 90% of patients were extubated early; but outside these hours, only 50% of patients were extubated early (OR, 6.6; 95% CI, 3.59 – 10.22; P < .001)

"This means that an intervention with potential complications such as an extubation could, and often will, be delayed until the next day if it's not deemed necessary to do it straightaway," said Fandler-Höfler.

There are usually ongoing discussions about which interventions should be performed as soon as possible and which can wait until the next day, he noted.

"Our research indicates that the specific intervention of extubation after stroke thrombectomy should be performed as early as safely possible," he said.

This can take place after the intervention in the angiography suite or directly after admission to an intensive care unit after the procedure, Fandler-Höfler added.

Findings from the study were published recently in the European Journal of Neurology.

Fandler-Höfler has reported no relevant financial relationships.

Congress of the European Academy of Neurology (EAN) 2020: Oral session. Presented May 25, 2020.

Eur J Neurol. Published online March 17. 2020. Abstract

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