Stroke Severity: Icu Admission And Recovery

A stroke is a common and potentially debilitating neurological condition that may require intensive care unit (ICU) admission. The treatment for a stroke depends on its severity and the parts of the brain affected. Patients with severe strokes may need to be admitted to the ICU due to breathing problems, a drop in consciousness, and impaired swallowing, speech, and other bodily functions.

ICU admission criteria for stroke patients vary across countries. For example, in the United States, severe strokes, defined by a National Institute of Health Stroke Scale (NIHSS) score of >17, constitute about 15-20% of cerebrovascular accidents requiring ICU admission. In contrast, in Nigeria, severe strokes account for about 5.6% of ICU admissions.

The outcome for patients with acute stroke requiring ICU admission is generally poor, with a high mortality rate. In one study, patients with severe strokes admitted to the ICU were four times more likely to die compared to non-stroke patients. Additionally, older age and reduced consciousness at ICU admission were associated with poorer outcomes.

Rehabilitation after a stroke is crucial and should ideally begin as early as possible, even for patients in the ICU. This includes regaining cognitive and motor skills, increasing independence, and reducing the risk of hospital readmission.

ICU admission criteria for stroke patients

Stroke patients may be admitted to the Intensive Care Unit (ICU) for various reasons, including respiratory or hemodynamic needs, and to minimize the risk of secondary brain injury and complications from reperfusion therapy. The decision to admit a stroke patient to the ICU is often based on the severity of the stroke and the patient's overall health condition. Here are some factors to consider when determining whether a stroke patient should be admitted to the ICU:

• Severity of Stroke: Stroke severity is typically assessed using the National Institute of Health Stroke Scale (NIHSS). A NIHSS score of >17 indicates a severe stroke, which may require ICU admission.
• Respiratory Failure: Patients with severe stroke may experience respiratory failure and require mechanical ventilation. This is one of the main indications for ICU admission.
• Hemodynamic Instability: Stroke patients with unstable blood pressure that is difficult to control may benefit from the close monitoring and specialized care provided in the ICU.
• Acute Respiratory Failure: Patients with acute respiratory failure due to stroke may require ICU admission for respiratory support and monitoring.
• Cardiac Arrest: Stroke patients who experience cardiac arrest may need ICU admission for advanced cardiac life support and monitoring.
• Age: Older age is a factor to consider, as older patients may have a higher risk of complications and a poorer prognosis.
• Comorbidities: The presence of other medical conditions, such as heart disease or diabetes, may influence the decision for ICU admission.
• Neurological Failure: Patients with severe neurological deficits, such as impaired consciousness or coma, may require ICU admission for close monitoring and management.
• Previous Health Status: The patient's previous health status and functional independence may be considered when deciding on ICU admission.
• Stroke Type: The type of stroke, such as ischemic or hemorrhagic, may influence the decision for ICU admission, as they have different management approaches and prognoses.
• Available Resources: The availability of ICU beds, specialized equipment, and staff expertise may also play a role in the decision for ICU admission.

It is important to note that the decision for ICU admission should be made on a case-by-case basis, considering the individual patient's needs and the resources available. Additionally, the benefits of ICU admission for stroke patients remain controversial, and further research is needed to determine the most appropriate criteria and the impact on patient outcomes.

Treatments for stroke in the ICU

Airway management and ventilatory support

Endotracheal intubation is required for acute stroke patients who experience a failure in adequate oxygenation or ventilation. Intubation may also be necessary for patients who are unable to protect their airway due to a reduced level of consciousness or impaired oropharyngeal function. The need for intubation is often anticipated based on the location of the infarct, but clinical indicators such as dysarthria and an inability to manage secretions are more reliable.

All acute stroke patients are kept nothing-by-mouth until a swallow screening can be performed to assess their risk of aspiration. Patients at risk for aspiration are positioned with the head of the bed elevated between 15 and 30 degrees.

Extubation is typically successful when acute stroke patients have regained sufficient oropharyngeal control, and extubation is rarely the limiting factor. Tracheostomy surgery may be required for patients who fail extubation or are not expected to recover oropharyngeal function for a prolonged period.

Blood pressure management

Blood pressure is often elevated in the acute phase of ischemic stroke to maximise perfusion of the ischemic tissue. However, lower blood pressure in the acute setting has been associated with worsening neurological outcomes, and highly elevated blood pressure is considered detrimental. Therefore, it is recommended to avoid extremes of blood pressure while allowing for autoregulation of systolic blood pressure in the initial 24 hours.

Induced hypertension

In rare cases, induced hypertension may be beneficial for patients who show fluctuations in their neurological exam associated with changes in blood pressure. This involves artificially augmenting blood pressure to improve cerebral blood flow and recruit collaterals.

Management of cerebral edema

Cerebral edema, or the accumulation of excess fluid in the brain, can lead to increased intracranial pressure (ICP) and further brain injury. Intermittent administration of hyperosmolar agents such as mannitol and hypertonic saline is the mainstay of cerebral edema treatment. These agents work by drawing water out of the brain tissue, thereby reducing swelling.

Invasive ICP monitoring is not typically used in ischemic stroke, and the effect of monitoring and treating ICP on patient outcomes is unknown. Conservative measures to maximise cerebral venous outflow and minimise the blood volume contribution to ICP are recommended.

Decompressive craniectomy

Decompressive craniectomy is a surgical procedure that involves removing a portion of the skull to allow the brain to expand and reduce intracranial pressure. Multiple randomised trials have demonstrated the efficacy of hemicraniectomy in improving survival and outcomes following hemispheric MCA infarction with malignant edema in patients under the age of 60.

Management of hemorrhagic transformation

Post-stroke hemorrhagic transformation refers to bleeding within the infarct, which can lead to neurological deterioration. The most reliable predictor of hemorrhagic transformation is infarct size, with larger infarcts associated with higher risk.

To manage hemorrhagic transformation, it is important to reverse coagulopathy and manage blood pressure. Bleeding in the setting of elevated INR (International Normalised Ratio) from warfarin can be reversed using fresh frozen plasma or prothrombin complex concentrates.

Prevention of early recurrent stroke/stroke progression

Aspirin is the mainstay of therapy following acute stroke, as it has been shown to reduce recurrent stroke and improve mortality. Dual antiplatelet therapy or anticoagulation may be considered for patients with substantial intracranial arterial atherosclerosis or those at high risk of embolisation.

Recovery from a stroke

The road to recovery after a stroke is often long and uncertain, and it can be different for everyone. However, there are some common patterns in the stroke recovery timeline.

Day 1: Initial Treatment

If you experience a stroke, you will likely be taken to an emergency department first to stabilize your condition and determine the type of stroke. If it is an ischemic stroke, clot-busting medication can help reduce long-term effects if you are treated in time. Depending on the stroke's severity, you may need to spend time in intensive care. Starting rehabilitation as soon as 24 hours after a stroke is vital for recovery. The rehabilitation team includes physiatrists, neurologists, physical and occupational therapists, speech-language pathologists, and nurses.

First Few Weeks After a Stroke

The typical length of a hospital stay after a stroke is five to seven days. During this time, the stroke care team will evaluate the effects of the stroke, which will determine the rehabilitation plan. The long-term effects of a stroke vary from person to person but may include cognitive, physical, and emotional symptoms, heavy fatigue, and trouble sleeping. Therapy sessions are conducted up to six times each day while the patient is at the hospital, helping to evaluate the damage and jump-start the recovery.

1-3 Months Post-Stroke

The first three months after a stroke are crucial for recovery, and most improvements will happen during this time. The goal of rehabilitation is to restore function as closely as possible to pre-stroke levels or develop compensation strategies to work around functional impairments. During this time, most patients will enter and complete an inpatient rehabilitation program or make significant progress in their outpatient therapy sessions.

The 6-Month Mark and Beyond

After six months, improvements are still possible but will be much slower. Most stroke patients reach a relatively steady state at this point, with some making a full recovery while others experience ongoing impairments, also called chronic stroke disease. Even though recovery slows down, it is still crucial to continue following up with your care team, including your primary care physician, a rehabilitation physician, physical and occupational therapists, a neurologist, and a rehabilitation psychologist.

Stroke rehab in the ICU

Stroke rehabilitation should begin as soon as the patient is stable, ideally on the first day, even for patients in the neuro ICU. This early intervention can help patients regain cognitive and motor skills, increase independence, and reduce the risk of hospital readmission.

The type of rehabilitation facility will depend on the intensity of care required. Inpatient rehabilitation facilities provide hospital-level care for patients who need 24-hour supervision by a rehabilitation physician. Patients usually stay for two to three weeks and participate in an intensive, coordinated rehabilitation program, including at least three hours per day of physical, occupational, and speech therapy.

Skilled nursing facilities are for patients who no longer need hospital care but still require some nursing services and a less intensive rehabilitation program. Long-term acute care hospitals provide extended medical and rehabilitation care to people with complex medical needs, such as those requiring regular ventilation.

Home and outpatient rehabilitation programs are also an option, with services ranging from skilled nursing care to limited assistance with daily tasks. Tele-rehabilitation is a viable option for continued rehabilitation support once the patient returns home.

Mortality rates of stroke patients in the ICU

Stroke patients are often initially managed in a stroke ward. However, severe stroke patients, defined as those with a National Institute of Health Stroke Scale (NIHSS) score of >17, will require admission into the Intensive Care Unit (ICU). In the United States of America, severe stroke accounts for about 3-6% of ICU admissions.

The benefit of ICU admission for stroke patients remains controversial. Previous studies have reported that there was no significant reduction in mortality and morbidity following admission of stroke patients to the ICU. In most cases, ICU admission has been found only to prolong patients’ inevitable demise after a severe stroke.

Mortality rates following a severe stroke in the ICU vary from one centre to another. A study by Marik at the University of Massachusetts, USA, found that ICU mortality was 28%, with 15% in-hospital deaths. In contrast, Burtin and colleagues at the Centre Hospitalier, Universitaire de Nancy, France, reported a higher ICU mortality rate of 73% and a one-year mortality rate of 92%.

A study conducted at the University of Benin Teaching Hospital, Benin, Nigeria, found that stroke patients admitted to the ICU had a mortality rate of 77.8%. Patients with severe stroke admitted to the ICU were four times more likely to die compared to non-stroke patients in the ICU.

Another study, which analysed data from a nationwide database in the United States between 2010 and 2017, found that the in-hospital stroke mortality rate declined from 4.8% in 2010 to 2.1% in 2017. This decline was independent of stroke etiology.

A prospective study of 181 acute ischemic stroke patients aged between 40 and 90 years found that one- and three-month mortality was associated with NIHSS and modified Rankin scale (MRS) scores at admission and three months. The same study also found that one- and three-month mortality and ICU admission had a statistically significant relationship with parenteral nutrition and pneumonia onset.

While the benefit of ICU admission for stroke patients remains controversial, stroke patients in the ICU have high mortality rates, which are independent of the type and route of admission.

Frequently asked questions