Elective intubation for neurologic deterioration after stroke

OBJECTIVE: To provide data to guide physicians and family when deciding whether a patient should be electively intubated after ischemic stroke. DESIGN: Chart review and patient interview. Clinical course, neurologic outcome, and financial and psychosocial effect of the decision to intubate were determined. SETTING: Neurology/Neurosurgery critical care unit. PATIENTS: Of our last 250 acute carotid territory ischemic stroke cases, we found 20 patients (8%) who were electively intubated, after CT and neurologic assessment, for neurologic deterioration. INTERVENTIONS: All patients received standard medical therapy. RESULTS: Intubation occurred 3 hours to 7 days (mean, 41 hours) after the onset of symptoms; six of 20 patients required intubation within the first 6 hours. Once clinical deterioration began, 10 of 20 patients required intubation within 1 hour. Six of 20 patients were discharged alive; two subsequently died, one is mostly dependent, two became mostly independent (one of these had a hemicraniectomy and is still improving, and the other died of an intercurrent illness 4 years after her stroke), and one is totally independent. The four "good" outcome survivors were distinguished by higher Glasgow Coma Scale scores (9. 2 versus 5. 9), and extubation was usually possible within 72 hours. For nonsurvivors, mean hospitalization after intubation was 6. 4 days. In survivors, the monthly uninsured cost was 0 to 2, 000, and caregivers experienced moderate stress. The same decision would be repeated by 76% of caregivers; 53% of caregivers would want intubation for themselves. CONCLUSIONS: Satisfactory outcome is possible in the 8% of ischemic stroke patients requiring elective intubation. Possible predictors of good outcome include less severe depression of consciousness at the time of intubation, extubation within 3 days, and hemicraniectomy. In retrospect, most families would repeat the decision to intubate. Further study in more patients of the cost/benefit of cerebral resuscitation after stroke is greatly needed.