Intensive care unit management of the stroke patient

Paediatric arterial ischemic stroke: acute management, recent advances and remaining issues

Stroke is a rare disease in childhood with an estimated incidence of 1-6/100.000. It has an increasingly recognised impact on child mortality along with its outcomes and effects on quality of life of patients and their families. Clinical presentation and risk factors of paediatric stroke are different to those of adults therefore it can be considered as an independent nosological entity. The relative rarity, the age-related peculiarities and the variety of manifested symptoms makes the diagnosis of paediatric stroke extremely difficult and often delayed. History and clinical examination should investigate underlying diseases or predisposing factors and should take into account the potential territoriality of neurological deficits and the spectrum of differential diagnosis of acute neurological accidents in childhood. Neuroimaging (in particular diffusion weighted magnetic resonance) is the keystone for diagnosis of paediatric stroke and other investigations might be considered according to the clinical condition. Despite substantial advances in paediatric stroke research and clinical care, many unanswered questions remain concerning both its acute treatment and its secondary prevention and rehabilitation so that treatment recommendations are mainly extrapolated from studies on adult population. We have tried to summarize the pathophysiological and clinical characteristics of arterial ischemic stroke in children and the most recent international guidelines and practical directions on how to recognise and manage it in paediatric emergency.

Ischemic stroke in infants and children: practical management in emergency

Stroke is a rare disease in children, with an estimated incidence 13/100000 and a significant impact on morbidity and mortality. Clinical presentation and risk factors, present in almost half of pediatric patients, are not the same as in adults. The diagnosis of stroke in children is often delayed because signs and symptoms can be subtle and nonspecific. History and clinical examination should exclude underlying diseases or predisposing factors. Neuroimaging is crucial in defining diagnosis. Other tests might be necessary, according to the clinical picture. We present here the most recent practical directions on how to diagnose and manage arterial stroke in children, according to different international guidelines on the subject.

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.

Advances in perinatal ischemic stroke

Increasingly distinct patterns of focal ischemic injury in the fetal and perinatal brain are recognized. Improved classification has afforded advances in risk factor identification, pathophysiology hypotheses, outcome prediction, and potential avenues for intervention. Cerebrovascular occlusion leading to perinatal stroke may be arterial or venous, symptomatic or subclinical, and it can occur across multiple time frames. Distinguishing causative factors from mere associations represents a major challenge with important implications for studies of pathogenesis. The adverse outcomes suffered by most children highlight the need for further research. Reviewed here are the current understandings, recent advancements, and future directions for research in perinatal ischemic stroke.

Management of acute ischemic stroke

Stroke is the third leading cause of death and the leading cause of disability in the United States. This article summarizes the management of acute ischemic stroke, including conventional and novel therapies. The article provides an overview of the initial management, diagnostic work-up, treatment options, and supportive measures that need to be considered in the acute phase of ischemic stroke.

Critical care of acute ischemic stroke

Stroke is the third leading cause of death and the leading cause of disability in the United States. This article summarizes the critical care of acute ischemic stroke, including conventional and novel therapies. The article provided an overview of the initial management, diagnostic workup, treatment options, and supportive measures that need to be considered in the acute phase of ischemic stroke.

Neurologic and non-neurologic predictors of mortality in ischemic stroke patients admitted to the intensive care unit

BACKGROUND/PURPOSE

Patients with severe strokes may have different associated medical comorbidities from those with mild strokes. This study evaluated the neurologic and non-neurologic medical predictors of mortality in patients with severe cerebral infarction in the acute stage.

METHODS

Patients admitted to a neurologic intensive care unit (ICU) due to cerebral infarction were included. Neurologic and non-neurologic predictors for in-unit mortality were determined by logistic regression analyses. Two models using (A) neurologic factors and (B) combined neurologic and non-neurologic factors as mortality predictors were developed. The performance of the models in predicting overall, neurologic and non-neurologic mortalities was compared by areas under the receiver-operating characteristic curves (AUC) of the derived regressive equations.

RESULTS

Of 231 patients with cerebral infarction admitted to the ICU, 34 (14.7%) died during ICU stay. Conscious state and acute physiologic abnormalities were significant predictors of mortality. The length of ICU stay in patients with non-neurologic mortality was longer than in those with neurologic mortality (p = 0.044). The AUC of Model B was larger than that of Model A in predicting overall (0.768 +/- 0.045 vs. 0.863 +/- 0.033, p = 0.005) and non-neurologic mortalities (0.570 +/- 0.073 vs. 0.707 +/- 0.074, p = 0.009), while there was no difference in predicting death from neurologic causes (0.858 +/- 0.044 vs. 0.880 +/- 0.032, p = 0.217).

CONCLUSION

Impaired consciousness and acute physiologic abnormalities are independent predictors of mortality for severe ischemic stroke during the acute stage. Neurologic factors predict early mortality from intrinsic cerebral dysfunction, while non-neurologic factors, especially the associated physiologic abnormalities, predict late mortality from medical complications.

Stroke in the fetus and neonate

Multiple patterns of focal ischemic injury in the fetal and perinatal brain are now recognized as important causes of neurological disability in children. Strokes may be arterial or venous, symptomatic or subclinical, and can occur across multiple timeframes. Establishing the importance of an increasing number of potential risk factors and translating that knowledge into an improved understanding of pathophysiology are major challenges. Advanced neuroimaging has facilitated increased recognition of perinatal stroke and an improved understanding of plasticity mechanisms in the developing brain. Better outcome prediction will assist in patient selection for advancing neuroprotective strategies to reduce cerebral palsy and other adverse outcomes suffered by most children.

Cerebral palsy secondary to perinatal ischemic stroke

Congenital hemiplegia is the most common form of cerebral palsy in children born at term, and stroke is the number one cause. Neonatal ischemic stroke includes perinatal arterial ischemic stroke, presumed pre- or perinatal stroke, and cerebral sinovenous thrombosis, all of which have emerged as important contributors to cerebral palsy. Of increasing interest is how the overlapping list of associations and risks for stroke and cerebral palsy relate to each other. Stroke-induced injury is focal, and the preservation of normal areas of brain may afford unique opportunities for plastic adaptation. The implications of this essential difference are stressed in a discussion of how the epidemiology, pathophysiology, diagnosis, and therapeutic advancements in perinatal stroke relate to the outcome of cerebral palsy.

Therapeutic approaches and advances in pediatric stroke

Evidence-based therapeutic interventions for pediatric ischemic cerebrovascular disease are beginning to emerge. The primary therapeutic target is usually the pathological prothrombotic disturbance that underlies the majority of pediatric stroke. A battle between anticoagulation and anti-platelet therapies continues to provide controversy and is the inspiration for upcoming randomized trials. Supportive care and neuroprotective strategies are an important consideration in children with stroke. Attempts to determine the safety of acute thrombolytic interventions are also underway. Finally, unique medical and surgical treatments for specific diseases leading to stroke in children continue to evolve. After briefly summarizing the epidemiology, pathophysiology, diagnosis, and outcomes of ischemic strokes in children, treatment approaches and alternatives will be reviewed in detail with emphasis placed on current areas of controversy and future directions for clinical research.

Airway management in neurological emergencies

Several neurological conditions may present to the emergency department (ED) with airway compromise or respiratory failure. The severity of respiratory involvement in these patients may not always be obvious. Proper pulmonary management can significantly reduce the respiratory complications associated with the morbidity and mortality of these patients. Rapid sequence intubation (RSI) is the method of choice for definitive airway management in the ED and is used for the majority of intubations. The unique clinical circumstances of each patient dictates which pharmacological agents can be used for RSI. Several precautions must be taken when using these drugs to minimize potentially fatal complications. Noninvasive positive pressure ventilation may obviate the need for intubation in a select population of patients. This article reviews airway management, with a particular emphasis on the use of RSI for common neurological problems presenting to the ED.

Recommendations for Comprehensive Stroke Centers

Background and Purpose— To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease.

Summary of Review— A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors.

Conclusions— There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.

Post-emergency department management of stroke

All stroke patients ideally should be admitted to a stroke unit in which personnel are familiar with strategies for taking care of stroke patients. Prevention of worsening cerebral ischemia by appropriate blood pressure and serum glucose management, fever control, and supplemental oxygen for hypoxemic patients is recommended. Recognition of common complications, such as aspiration pneumonia and deep venous thrombosis, highlights the need for swallowing evaluation and the use of pneumatic compression devices or subcutaneous heparin. Patients should be monitored closely for deterioration in their neurologic status and should have complications appropriately addressed. After evaluation of stroke etiology, appropriate secondary stroke prophylaxis should be selected and initiated before hospital discharge.