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GeertMeyfroidtPierre-EdouardBollaertPaulE.
MarikAcuteischemicstrokeintheICU:toadmitornottoadmitReceived:1April2014Accepted:1April2014Publishedonline:8April2014Springer-VerlagBerlinHeidelbergandESICM2014G.
Meyfroidt())IntensiveCareMedicine,KULeuven,Line1:UZLeuven,3000Louvain,Belgiume-mail:geert.
meyfroidt@uzleuven.
beP.
-E.
BollaertServicedeReanimationMedicale,CHUdeNancy,Nancy,FranceP.
E.
MarikEasternVirginiaMedicalSchool,Norfolk,VA,USAAcuteischemicstroke(AIS)isanimportanthealth-careproblemworldwide,andasignicantcauseofdisabilityaswellasmortality.
TheincidenceofAISisexpectedtoincreaseinthefuture,becausethemajorityofAISarecausedbycardio-embolicdisordersandatherosclerosis,typicalfortheageingpopulation.
OnlytwointerventionsinsmallsubsetsofpatientshavebeendemonstratedtoimprovetheoutcomeofAISpatients.
ThesinglemostimportantinterventiontoalterthenaturalhistoryofAISandimprovethepatients'functionaloutcomeisthetimelyadministrationofathrombolyticagent(intra-venousrt-PA)intheappropriatepatientwithinthenarrow4.
5-hwindow[1].
Endovasculartherapyrepresentsanalternativetherapytointravenousrt-PAinthosewhoarenotcandidatesforintravenousrt-PA,buthasnoadvantageoverintravenousrt-PA[2].
Hemisphericdecompressioninpatientslessthan60yearsofagewithmalignantmiddlecerebralarteryterritory(MCA)infarctionandspace-occu-pyingbrainoedemahasbeendemonstratedtoimproveoutcome.
Thisresultwasconrmedinanindividualpatientmeta-analysis,demonstratingamarkedimprovementinneurologicalrecoveryandsurvival[3].
Fortheagegroupolderthan60yearsofagewithmalignantMCAinfarction,whoareover-representedintheAISpatientgroup,therecentlypublishedDESTINYIItrialwasabletodemon-stratethatdecompressionwasalsoabletoreducemortality,butnotinuencetheproportionofpatientswithseveredisability[4].
Despiteinitialpromise,neuroprotectiveagentshavefailedtoshowabenetinthemanagementofAIS[5],ashavetightglycaemiccontrol[6],highdosealbumin[7]andtheuseofanti-hypertensiveagents[8,9].
Today,increasingnumbersofpatientswithAISareadmittedtoanintensivecareunit(ICU)forvariousindi-cations.
InthisissueofIntensiveCareMedicine,Kirkmanetal.
presentastateoftheartreviewoftheICUmanage-mentofpatientswithAIS[10].
Theirreviewisverythoroughandprovideskeyrecommendationsontheaforementionedinterventions.
Unfortunately,theywerenotabletoprovidemuchevidence-basedguidanceastowhichpatientsshouldbeadmittedtotheICU,andwhichsubgroupsofAISpatientscouldactuallybenetfromICUmanagement.
TheguidelinesoftheSocietyofCriticalCareMedicinestatethat''ingeneralICUsshouldbereservedforthosepatentswithreversiblemedicalconditionswhohaveareasonableprospectofsubstantialrecovery''[11].
InherentinthisguidelineasitappliestotheAISpatient,istheassumptionthattheintensivisthasanarsenaloftherapeuticinterventionswhichwillalterthecourseofthepatient'sstrokeandthattheseinterventionswillimprovethepatient'soutcome.
IfwetakealookatthedataonmechanicalventilationinAISpatients,probablyoneofthemainindicationsforreferraltoanICU,notsurprisingly,therequirementformechanicalventilationinitselfappearstobeassociatedwithbothahighershort-andlong-termmortality.
Usingalargeadministrativedatabasecovering93countiesintheeasternhalfoftheUSA,Golestanianetal.
[12]evaluatedtheoutcomesof31,301AISpatients.
The30-dayand1-yearmortalitywas64%and81%respec-tivelyinthosepatientswhorequiredmechanicalventilationcomparedto16%and35%inthosepatientswhodidnotrequiremechanicalventilation.
Anumberofsmallerstud-ies(lessthan100patientseach)haveaddressedthisquestionaswell.
ThesestudiesconrmedtheobservedhighIntensiveCareMed(2014)40:749–751DOI10.
1007/s00134-014-3289-5EDITORIAL1-yearmortalityforpatientsrequiringmechanicalventi-lation,37–87%,withnoclearevidenceofimprovementovertime[13–18].
Furthermore,severedisabilitywasobservedin20–45%ofsurvivors.
InthisdiscussiononthebenetofmechanicalventilationfortheoutcomeofAIS,thereasonwhymechanicalventilationwasinitiatedmightbeimportant.
Unfortunately,thiswasonlyassessedinfourofthesestudies(Fig.
1)[13–16].
Althoughthepopulationsamplesincludedinthelatterstudiesweresmall,thesedatasuggestthatthosepatientsintubatedandventilatedforcomaorneurologicdeteriorationmaynotbenetfrommechanicalventilation.
Thelackofdataontheoutcomebenetofspecicther-apeuticinterventionstoimprovetheoutcomeofthemajorityofpatientssufferingfromAIScertainlydoesnotimplythatphysiciansshouldadoptafatalisticapproachwhenmanag-ingthesepatients.
Anumberofwell-conductedclinicaltrialshavedemonstratedthatthemortalityandfunctionalrecoveryofpatientsfollowingastrokearesignicantlyimprovedwhenthesepatientsarecaredforinaspecializedstrokeunitascomparedtoageneralmedicalward[19,20].
Theseunitsprovidespecializednursingcareandawell-organizedmul-tidisciplinaryrehabilitationprogram.
Strokeunitcarereducesthemedicalcomplicationsinthesepatientsandallowsforearlierandmoreintenserehabilitation.
Incontrasttothis,specicstrokeICUswereaban-donedinthe1970safteritwasdemonstratedthatsuchunitshadverylittleimpactontheoutcomeofpatientsfollowingastroke.
Nevertheless,aproportionofpatientswhosufferfromstrokemaybenetfromadmissiontotheICU.
Endotrachealintubationandmechanicalventilationshouldbereservedforpatientswithreversiblerespiratoryfailurewhoarelikelytohaveagoodprognosisforafunctionalrecovery,e.
g.
inthetreatmentandpreventionofaspirationpneumoniaduetotemporallossofbulbarfunction,occurringin37–78%ofstrokepatients[21].
LargeMCAstrokeswhomayrequiredecompressivecraniectomy,regardlessoftheirage[3,4],andspace-occupyingcerebellarinfarctionsaccessibletoapromptsurgicaldecompression[22]areaclearindicationforICUadmission.
Insomecases,themanagementofbloodpressure,orseizures,mightnecessitateanICUadmission.
FurtherresearchshouldfocusontheuseofvalidatedstrokeseverityscoringsystemssuchastheNIHStrokeScale(NIHSS)ortheTriageStrokePanel(MMX),takingintoaccounttheinitialclinicalevolutionofthesepatients[23],toidentifythosepatientswhowillbenetfromICUreferral.
Itisclearthataggressivemedicalmeasuresindeeplycomatosepatients,withalowprobabilityofafavourableoutcomeareaformofnon-benecialcare,whichwillonlyincreasetheburdenonpatients,familiesandthehealth-caresystem.
Theparadigmof''lessmaybemore''wouldappeartobeappropriateforthesepatients[24].
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