Mechanical Ventilation in Stroke

Source: Wijdicks EFM, Scott JP. Causes and outcome of mechanical ventilation in patients with hemispheric ischemic stroke. Mayo Clin Proc 1997;72:210-213.

Wijdicks and scott describe outcomes of 24 patients with acute middle cerebral artery (MCA) ischemic stroke who were intubated and mechanically ventilated after admission. Indications included seizures, airway obstruction, and poor blood gases (6), brain swelling (8), or pulmonary edema (10). Seventeen patients received assisted and seven mandatory ventilation. The 10 patients with pulmonary edema received diuretics, nitroprusside, or dopamine; six had heart failure, of whom one also had a mural thrombosis and two had acute anterior myocardial infarctions. Seventeen patients died; seven survived. Of the survivors, four who had seizures before intubation regained independent function, as did one with acute pulmonary edema.

The authors emphasize that the occurrence of early seizures in MCA stroke and their treatment with benzodiazepines may precipitate a need for airway protection, but the chance of subsequent satisfactory outcome is higher than in patients ventilated for other reasons. Otherwise, prognosis was dismal, with only one nonseizure patient regaining independent function. As the authors point out, Grotta et al also report a poor outcome in acute stroke among patients needing intubation and ventilation. Only three of 20 recovered a mostly independent outcome in that study (Neurology 1995;45:640-644). It would seem useful for those who choose to apply ventilatory life support for stroke patients to establish an interinstitutional analysis of the outcome and costs of such measures in relation to acute disability. Follow-up should be not only at discharge but at three and six months. Only large-number studies will help to establish the risks and benefits of intubating patients with severe supratentorial stroke. —fp