Outcomes of Patients Admitted to the ICU for Acute Stroke

A Retrospective Cohort

Thibaut Carval; Charlotte Garret; Benoôt Guillon; Jean-Baptiste Lascarrou; Maëlle Martin; Jérémie Lemarié; Julien Dupeyrat; Amélie Seguin; Olivier Zambon; Jean Reignier; Emmanuel Canet

Disclosures

BMC Anesthesiol. 2022;22(235)

Conclusion

Most patients admitted to the ICU for stroke had severely impaired consciousness, required mechanical ventilation, and were ineligible for acute-phase stroke therapy. Three fifths of patients died, and only one fifth had a good 6-month neurological outcome. Older age and worse consciousness impairment at ICU admission were independently associated with poorer outcomes. Further studies are needed to identify criteria for choosing the most appropriate level of ICU care in patients with acute stroke.

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Abbreviations
APACHE II: Acute Physiology And Chronic Health Evaluation II; ARDS: Acute Respiratory Distress Syndrome; CI: confidence interval; GCS: Glasgow Coma Scale; ICD-10: International Classification of Diseases, 10th revision; ICU: intensive care unit; IQR: interquartile range; mRS: modified Rankin Scale; NIHSS: National Institute of Health Stroke Score; OR: odds ratio; SAPSII: Simplified Acute Physiology Score version II.

Acknowledgments
We thank Antoinette Wolfe, MD, for assistance in preparing and reviewing the manuscript.

Funding
None.

Availability of data and materials
The dataset generated during and analyzed during the current study are not publicly available according to the French law but are available from the corresponding author on reasonable request.

Declarations
Ethics approval and consent to participate
The study was performed in accordance with Good Clinical Practices and the Declaration of Helsinki principles for ethical research. It was approved by the ethics committee of the French Intensive Care Society (CE SRLF 21–09) on January 25, 2021. In accordance with French law on retrospective studies of anonymized healthcare data, informed consent was obtained from all patients and/or their next of kin.

Consent for publication
Not applicable.

Table 1. Baseline characteristics of the 323 study participants
Variable	All patients (n = 323)
Demographics
Age (years), median [IQR]	67 [54.5–77]
Male, n (%)	173 (53.6)
Comorbidities, n (%)
Hypertension	155 (48)
Coronary artery disease	76 (23.5)
Dyslipidemia	73 (22.6)
Atrial fibrillation	61 (18.9)
Previous stroke	49 (15.2)
Diabetes mellitus	40 (12.4)
Chronic medications, n (%)
Anticoagulation therapy	88 (27.2)
Antiplatelet therapy	65 (20.1)
Stroke type, n (%)
Hemorrhagic	248 (76.8)
Ischemic	75 (23.2)
Brain site affected, n (%)
Ischemic stroke
Anterior circulation	52 (69.3)
Posterior circulation	23 (30.7)
Cerebral hemorrhage
Lobar	178 (71.8)
Deep	40 (16.1)
Infratentorial	30 (12.1)
Clinical variables at ICU admission
Glasgow Coma Scale score, median [IQR]	6 [4–10]
Loss of pupillary light reflex, n (%) ^a	112 (34.7)
SAPS II, median [IQR]	54 [35–64]
Type of ICU admission, n (%)
Admission from emergency room or home	283 (87.6)
Transfer from ward	40 (12.4)
Reason for ICU admission^b, n (%)
Altered consciousness	281 (87)
GCS 13–15	25 (7.7)
GCS 9–12	39 (12.1)
GCS 3–8	217 (67.2)
Hemodynamic instability	91 (28.2)
Respiratory failure	84 (26)
Cardiac arrest	17 (5.3)

ICU intensive care unit, IQR interquartile range, SAPS II Simplified Acute Physiology Score, version II; GCS Glasgow Coma Scale
^aMissing data for 36 patients
^bSome patients had more than one reason for ICU admission

Table 2. ICU management and outcomes
Variable	All patients (n = 323)
Acute-phase stroke therapy, n (%)	81 (25.1)
External ventricular drainage	61 (18.9)
Surgical hematoma drainage	21 (6.5)
Craniectomy	19 (5.9)
Intravenous thrombolysis	9 (2.8)
Endovascular thrombectomy	9 (2.8)
Endovascular coiling of aneurysm	8 (2.5)
Stroke-related diagnoses, n (%)
Intracranial hypertension	188 (58.2)
Acute hydrocephalus	154 (47.7)
Pneumonia	60 (18.6)
Seizures	38 (11.8)
Status epilepticus	10 (3.1)
Events during the ICU stay
Mechanical ventilation, n (%)	257 (79.6)
Days on mechanical ventilation, median [IQR]	3 [2–6]
Tracheotomy, n (%)	11 (3.4)
Withdrawal or withholding of life-sustaining treatment, n (%)	124 (38.4)
Length of stay, days, median [IQR]
In the ICU	3 [2–7]
In the hospital	5 [2–17]
Vital status, n (%)
Died in the ICU	190 (58.8)
Died in the hospital	198 (61.3)
Died before month 6 (n = 313, lost to follow-up n = 10)	202 (64.5)

ICU intensive care unit, IQR interquartile range

Table 3. Logistic regression analyses to identify factors associated with a modified Rankin Scale score (mRS) of 0–2 6 months after ICU admission
Factors	Univariate analysis		Multivariable analysis
Factors	OR (95%CI)	P value	OR (95%CI)	P value
Age (per year)	0.94 (0.93–0.97)	< 0.01	0.93 (0.89–0.96)	< 0.01
Glasgow Coma Scale score (per point)	1.39 (1.26–1.54)	< 0.01	1.23 (1.07–1.40)	< 0.01
Hemorrhagic (versus ischemic) stroke	0.29 (0.15–0.56)	< 0.01	0.51 (0.17–1.52)	0.22
Persistent pupillary light reflex	12.81 (3.81–43.1)	< 0.01	3.71 (0.82–1.68)	0.09
Body temperature (per additional °C)	1.43 (1.03–1.99)	0.03	1.08 (0.73–1.61)	0.69
Mechanical ventilation	0.09 (0.04–0.18)	< 0.01
Acute-phase stroke therapy	1.77 (0.99–3.17)	0.05	0.66 (0.22–1.96)	0.45
SAPS II (per point)	0.92 (0.90–0.95)	< 0.01