Mechanical ventilation in patients with hemispheric ischemic stroke

Objective: Whether stroke patients should be ventilated mechanically is sti ll a contentious issue, because their outcome is very poor. We wanted to in vestigate how often mechanical ventilation is indicated in patients with he mispheric ischemic stroke as well as the outcome of these patients and the factors by which outcome is influenced. Design:Prospective case series. Setting: University hospital, neurocritical care unit. Subjects: Subjects were 218 patients who met the following inclusion criter ia: age 18-85 yrs, acute hemispheric ischemic infarction, clinical examinat ion, and computed tomography within 6 hrs after the onset of symptoms. Interventions: Mechanical ventilation was instituted with one or more of th e following conditions: deterioration of consciousness with the inability t o protect the airway; Pao(2) of <60; Pco(2) of >60 mm Hg; breath rate of >4 0 breaths/min; and left heart insufficiency with definitive or impending pu lmonary edema. Measurements and Main Results: Mechanical ventilation was indicated for 52 (24%) of the 218 patients: in 47 (90%) patients because of deterioration of consciousness, and in five (10%) patients because of heart insufficiency a nd/or pneumonia. In a logistic regression model, the history of hypertensio n and a size of infarction exceeding two thirds of the middle cerebral arte ry territory were independent variables for the application of mechanical v entilation. After 3 months, 42 (81%) of these 52 patients had died. The mos t common cause of death was fatal midbrain herniation caused by complete mi ddle cerebral artery infarction. Patients who survived had a good-to-fair o utcome. Conclusions:New therapeutic strategies (e.g., hemicraniectomy) must be deve loped to reduce mortality and improve the outcome for this subgroup of isch emic stroke patients. Mechanical ventilation is and will remain a crucial e lement within such new concepts.