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In-hospital and long term outcome following acute stroke. A single centre experience.

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In-hospital and long term outcome following acute stroke. A single centre experience.

Herrmann R, Tam K, Gauge N, McFadyen C, Khaku M, Brealey D
University College London Hospital, 235 Euston Road, London, NW1 2BU, United Kingdom 


Introduction

Stroke is associated with significant in- hospital mortality as well as morbidity in survivors. Variation in practice exists in the literature on withholding and withdrawing from organ support on Intensive care unit (ICU). Prognostication is an important determinant for decision for admission to Intensive care unit (ICU), withholding and withdrawal of treatment. Certain pathological and patient characteristics are recognised as strong predictors of long-term outcome, including stroke associated with pontine herniation, depth of coma, reason for intubation and associated medical complications such as pneumonia.2 Nevertheless, predictive scoring systems often include impractical variables and or lack predicting accuracy.

Mean in-hospital and 1-2 year mortality have been suggested as 55% (range 48-90%) & 68% (range 59-97%) respectively.1 The mean age of mechanically ventilated patient was reported as 64 years.1 Although age above 65 years is known as one of the strongest independent predictor of death, up to 40% 6- month survival rate has been reported in intubated patients age 65 or above.4,5 25% of elderly survivors recovered to good functional status a year or more after the acute event.5 There are more and more evidence to suggest that even the very elderly patients achieve reasonable recovery 1 year after admission for critical illness.6,7 However evidence on long-term outcome more than 1- 2 years after an episode of stroke is limited.

As a result of the huge variations in patient outcome and the difficulty to confidently prognosticate after acute stroke, management planning and communication with patient’s family remains a major challenge. 

Method

We reviewed the outcomes of acute stroke patients who were admitted to our ICU between December 2012 and 2014. Data was coded by two investigators and electronic information validated by looking directly at both internal and external imaging. We reviewed the patient’s record and contacted patients and patients’ GPs, 1-3 years following acute stroke events, to follow up on their progress, using the Modified Rankin Scoring system (MRS).

Results

85 patients were admitted to ICU between December 2012 and 2014. 59% were male. Mean age 72 (range 22-92). 71% suffered from ischaemic stroke; 29% haemorrhagic stroke. 40% was dependent to varying extent pre-admission. Sources of admission includes Emergency department, Acute Stroke Unit, other ICU in the trust and wards. 58% were admitted to ICU for low GCS, 22% for monitoring and medical optimisation, 14% medical complication including pneumonia, 4% peri-intervention such as coiling and 12% other. 19% had reported midline shift, 14% hydrocephalus & 24% intraventricular extension. 12 (14%) suffered seizures, 32 (38%) patient had documented pneumonia during the admission and 55 (65%) patients were ventilated for up to 21days. Mean age of mechanically ventilated patients was 70. Mean length of hospital stay is 27 days (range 1- 736 days); mean ICU stay is 10 days (range <1-335 days). 45 (53%) patients survived to hospital discharge and out of the 23 patients who were followed up, 14 (61%) patients were still alive up to 3 years following acute admission for stroke. Age of the survivors ranges from 22 to 88, with the eldest patient being able to walk unassisted 2 years after stroke. 

Conclusion

Although acute stroke is associated with high morbidity and mortality rates, our cohort of elderly patients has an overall lower mortality rate, with a larger proportion surviving for >1 years after discharged, compared with the reported literature. Even with the very elderly patients, some remained in good functional status more than 2 years after an acute stroke. Prognostication and decision for ICU admission remains a challenge in all age groups. A structured MDT approach both in hospital and the community is vital to patient’s physical and psychological recovery. 

References

  1. Holloway, R. G., et al. (2005). Prognosis and Decision Making in Severe Stroke. JAMA. 294(6), pp. 725-733

  2. Chang, W. H., et al. (2016). Predictors of functional level and quality of life at 6 months after a first-ever stroke: the KOSCO study. J Neuril. 263(6), pp. 1166- 1177

  3. Golestanian, E., et al. (2009). Long-term survival in older critically ill patients with acute ischaemic stroke. Crit Care Med. 37(12), pp. 3107-3113

  4. Steiner, T., et al. (1997). Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke. 28, pp. 711–5

  5. Foerch, C., et al. (2004). Survival and quality of life outcome after mechanical ventilation in elderly stroke patients. J Neurol Neurosurg Pschyatry. 75, pp. 988- 993

  6. Rabinstein, A. A. & Wijdicks, E. F. M. (2004). Outcome of survivors of acute stroke who require prolonged ventilatory assistance and tracheostomy. Cerebrovasc Dis. 18, pp. 325-331

  7. Heyland, D. K. et al. (2016). Predicting Performance Status 1 year after critical illness in patients 80 years or older: development of a multivariable clinical prediction model. Crit Care Med. 44(9), pp. 1718- 1726 




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