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Journal of Neurology

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01-10-2020 | Stroke | Original Communication

Newly developed stroke in patients admitted to non-neurological intensive care units

Authors: Sungyang Jo, Jun Young Chang, Suyeon Jeong, Soo Jeong, Sang-Beom Jeon

Published in: Journal of Neurology | Issue 10/2020

Abstract

Background

Little is known about newly developed stroke in patients admitted to the intensive care unit (ICU).

Objective

This study aimed to investigate characteristics and outcomes of newly developed stroke in patients admitted to the non-neurological intensive care units (ICU-onset stroke, IOS).

Methods

A consecutive series of adult patients who were admitted to the non-neurological ICU were included in this study. We compared neurological profiles, risk factors, and mortality rates between patients with IOS and those without IOS.

Results

Of 18,604 patients admitted to the ICU for non-neurological illness, 218 (1.2%) developed stroke (ischemic, n = 182; hemorrhagic, n = 36). The most common neurological presentation was altered mental status (n = 149), followed by hemiparesis (n = 55), and seizures (n = 28). The most common etiology of IOS was cardioembolism (50% [91/182]) for ischemic IOS and coagulopathy (67% [24/36]) for hemorrhagic IOS. In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (adjusted odds ratio [AOR] = 1.04, 95% CI = 1.03−1.06, P < 0.001), prothrombin time (AOR = 0.99, 95% CI = 0.98−0.99, P = 0.013), cardiovascular surgery (AOR = 1.84, 95% CI = 1.34−2.50, P < 0.001), mechanical ventilation (AOR = 6.75, 95% CI = 4.87−9.45, P < 0.001), and extracorporeal membrane oxygenation (AOR = 2.77, 95% CI = 1.62−4.55, P < 0.001) were related to the development of IOS. Stroke was associated with increased 3-month mortality after hospital discharge (AOR, 2.20; 95% CI, 1.58–3.05; P < 0.001), after adjustment for APACHE II and comorbidities.

Conclusions

Patients who developed IOS had characteristics of initial critical illness and managements performed in the ICU as well as neurological presentations. The occurrence of IOS was related to high morbidity and mortality.

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Park HJ, Cho HJ, Kim YD, Lee DW, Choi HY, Kim SM, Heo JH (2009) Comparison of the characteristics for in-hospital and out-of-hospital ischaemic strokes. Eur J Neurol 16(5):582–588. https://doi.org/10.1111/j.1468-1331.2009.02538.xCrossRefPubMed

Kimura K, Minematsu K, Yamaguchi T (2006) Characteristics of in-hospital onset ischemic stroke. Eur Neurol 55(3):155–159. https://doi.org/10.1159/000093574CrossRefPubMed

Farooq MU, Reeves MJ, Gargano J, Wehner S, Hickenbottom S, Majid A, Investigators PCNASRMP (2008) In-hospital stroke in a statewide stroke registry. Cerebrovasc Dis 25(1–2):12–20. https://doi.org/10.1159/000111494CrossRefPubMed

Saltman AP, Silver FL, Fang J, Stamplecoski M, Kapral MK (2015) Care and outcomes of patients with in-hospital stroke. JAMA Neurol 72(7):749–755. https://doi.org/10.1001/jamaneurol.2015.0284CrossRefPubMed

Pilato F, Profice P, Dileone M, Ranieri F, Capone F, Minicuci G, Tagliente D, Florio L, Di Iorio R, Plantone D, Tonali PA, Di Lazzaro V (2009) Stroke in critically ill patients. Minerva Anestesiol 75(5):245–250PubMed

Fransen PS, Beumer D, Berkhemer OA, van den Berg LA, Lingsma H, van der Lugt A, van Zwam WH, van Oostenbrugge RJ, Roos YB, Majoie CB, Dippel DW, Investigators MRCLEAN (2014) MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial. Trials 15:343. https://doi.org/10.1186/1745-6215-15-343CrossRefPubMedPubMedCentral

Blacker DJ (2003) In-hospital stroke. Lancet Neurol 2(12):741–746. https://doi.org/10.1016/s1474-4422(03)00586-6CrossRefPubMed

Jeon SB, Koh Y, Choi HA, Lee K (2014) Critical care for patients with massive ischemic stroke. J Stroke 16(3):146–160. https://doi.org/10.5853/jos.2014.16.3.146CrossRefPubMedPubMedCentral

Lee H, Lim CW, Hong HP, Ju JW, Jeon YT, Hwang JW, Park HP (2015) Efficacy of the APACHE II score at ICU discharge in predicting post-ICU mortality and ICU readmission in critically ill surgical patients. Anaesth Intensive Care 43(2):175–186. https://doi.org/10.1177/0310057x1504300206CrossRefPubMed

10.

Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, Kumar A, Sevransky JE, Sprung CL, Nunnally ME, Rochwerg B, Rubenfeld GD, Angus DC, Annane D, Beale RJ, Bellinghan GJ, Bernard GR, Chiche JD, Coopersmith C, De Backer DP, French CJ, Fujishima S, Gerlach H, Hidalgo JL, Hollenberg SM, Jones AE, Karnad DR, Kleinpell RM, Koh Y, Lisboa TC, Machado FR, Marini JJ, Marshall JC, Mazuski JE, McIntyre LA, McLean AS, Mehta S, Moreno RP, Myburgh J, Navalesi P, Nishida O, Osborn TM, Perner A, Plunkett CM, Ranieri M, Schorr CA, Seckel MA, Seymour CW, Shieh L, Shukri KA, Simpson SQ, Singer M, Thompson BT, Townsend SR, Van der Poll T, Vincent JL, Wiersinga WJ, Zimmerman JL, Dellinger RP (2017) Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 43(3):304–377. https://doi.org/10.1007/s00134-017-4683-6CrossRefPubMed

11.

Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd (1993) Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST Trial of Org 10172 in Acute Stroke Treatment. Stroke 24(1):35–41. https://doi.org/10.1161/01.str.24.1.35CrossRefPubMed

12.

Hemphill JC 3rd, Bonovich DC, Besmertis L, Manley GT, Johnston SC (2001) The ICH score: a simple, reliable grading scale for intracerebral hemorrhage. Stroke 32(4):891–897. https://doi.org/10.1161/01.str.32.4.891CrossRefPubMed

13.

Kang DW, Han MK, Kim HJ, Yun SC, Jeon SB, Bae HJ, Kwon SU, Kim JS (2012) New ischemic lesions coexisting with acute intracerebral hemorrhage. Neurology 79(9):848–855. https://doi.org/10.1212/WNL.0b013e3182648a79CrossRefPubMed

14.

Kim JY, Kang K, Kang J, Koo J, Kim DH, Kim BJ, Kim WJ, Kim EG, Kim JG, Kim JM, Kim JT, Kim C, Nah HW, Park KY, Park MS, Park JM, Park JH, Park TH, Park HK, Seo WK, Seo JH, Song TJ, Ahn SH, Oh MS, Oh HG, Yu S, Lee KJ, Lee KB, Lee K, Lee SH, Lee SJ, Jang MU, Chung JW, Cho YJ, Choi KH, Choi JC, Hong KS, Hwang YH, Kim SE, Lee JS, Choi J, Kim MS, Kim YJ, Seok J, Jang S, Han S, Han HW, Hong JH, Yun H, Lee J, Bae HJ (2019) Executive summary of stroke statistics in Korea 2018: a report from the epidemiology research council of the Korean stroke society. J Stroke 21(1):42–59. https://doi.org/10.5853/jos.2018.03125CrossRefPubMed

15.

Haitsma JJ, Schultz MJ, Hofstra JJ, Kuiper JW, Juco J, Vaschetto R, Levi M, Zhang H, Slutsky AS (2008) Ventilator-induced coagulopathy in experimental Streptococcus pneumoniae pneumonia. Eur Respir J 32:1599–1606. https://doi.org/10.1183/09031936.00045908CrossRefPubMed

16.

Pragliola C, Di Michele S, Galzerano D (2017) A case of shunting postoperative patent foramen ovale under mechanical ventilation controlled by different ventilator settings. Clin Pract 7:969. https://doi.org/10.4081/cp.2017.969CrossRefPubMedPubMedCentral

17.

Seok HY, Seo WK, Eun MY, Kwon DY, Park MH, Oh K (2010) Transient increase in intrathoracic pressure as a contributing factor to cardioembolic stroke. J Clin Neurol 6:212–215. https://doi.org/10.3988/jcn.2010.6.4.212CrossRefPubMedPubMedCentral

18.

Walkey AJ, Greiner MA, Heckbert SR, Jensen PN, Piccini JP, Sinner MF, Curtis LH, Benjamin EJ (2013) Atrial fibrillation among Medicare beneficiaries hospitalized with sepsis: incidence and risk factors. Am Heart J 165:949–955.e943. https://doi.org/10.1016/j.ahj.2013.03.020CrossRefPubMedPubMedCentral

19.

Zochios VA, Keeshan A (2013) Pulmonary embolism in the mechanically-ventilated critically ill patient: is it different? J Intensive Care Soc 14:36–44. https://doi.org/10.1177/175114371301400109CrossRef

20.

Dres M, Teboul JL, Monnet X (2014) Weaning the cardiac patient from mechanical ventilation. Curr Opin Crit Care 20:493–498. https://doi.org/10.1097/MCC.0000000000000131CrossRefPubMed

21.

Kim HJ, Jeong S, Jeon SB (2017) Documenting the invisible in stroke-like symptoms during extracorporeal membrane oxygenation. Intensive Care Med 43(4):566–567. https://doi.org/10.1007/s00134-016-4659-yCrossRefPubMed

22.

Szem JW, Hydo LJ, Fischer E, Kapur S, Klemperer J, Barie PS (1995) High-risk intrahospital transport of critically ill patients: safety and outcome of the necessary “road trip”. Crit Care Med 23(10):1660–1666. https://doi.org/10.1097/00003246-199510000-00009CrossRefPubMed

23.

Fanara B, Manzon C, Barbot O, Desmettre T, Capellier G (2010) Recommendations for the intra-hospital transport of critically ill patients. Crit Care 14(3):R87. https://doi.org/10.1186/cc9018CrossRefPubMedPubMedCentral

24.

Devlin JW, Skrobik Y, Gélinas C, Needham DM, Slooter AJC, Pandharipande PP, Watson PL, Weinhouse GL, Nunnally ME, Rochwerg B, Balas MC, van den Boogaard M, Bosma KJ, Brummel NE, Chanques G, Denehy L, Drouot X, Fraser GL, Harris JE, Joffe AM, Kho ME, Kress JP, Lanphere JA, McKinley S, Neufeld KJ, Pisani MA, Payen JF, Pun BT, Puntillo KA, Riker RR, Robinson BRH, Shehabi Y, Szumita PM, Winkelman C, Centofanti JE, Price C, Nikayin S, Misak CJ, Flood PD, Kiedrowski K, Alhazzani (2018) Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Crit Care Med 46:e825–e873. https://doi.org/10.1097/CCM.0000000000003299CrossRefPubMed

25.

Kim YS, Lee HJ, Jeon SB (2015) Management of pain and agitation for patients in the intensive care unit. J Neurocrit Care 8(2):53–65. https://doi.org/10.18700/jnc.2015.8.2.53CrossRef

26.

Jeon SB, Ryoo SM, Lee DH, Kwon SU, Jang S, Lee EJ, Lee SH, Han JH, Yoon MJ, Jeong S, Cho YU, Jo S, Lim SB, Kim JG, Lee HB, Jung SC, Park KW, Lee MH, Kang DW, Suh DC, Kim JS (2017) Multidisciplinary approach to decrease in-hospital delay for stroke thrombolysis. J Stroke 19(2):196–204. https://doi.org/10.5853/jos.2016.01802CrossRefPubMedPubMedCentral

27.

Jeon SB, Lee HB, Koo YS, Lee H, Lee JH, Park B, Choi SH, Jeong S, Chang JY, Hong SB, Lim CM, Lee SA (2020) Neurological emergencies in patients hospitalized with non-neurological illness. J Patient Saf. https://doi.org/10.1097/PTS.0000000000000682CrossRefPubMed

28.

Fiorelli M, Bastianello S, von Kummer R, del Zoppo GJ, Larrue V, Lesaffre E, Ringleb AP, Lorenzano S, Manelfe C, Bozzao L (1999) Hemorrhagic transformation within 36 hours of a cerebral infarct: relationships with early clinical deterioration and 3-month outcome in the European Cooperative Acute Stroke Study I (ECASS I) cohort. Stroke 30:2280–2284. https://doi.org/10.1161/01.str.30.11.2280CrossRefPubMed

Title: Newly developed stroke in patients admitted to non-neurological intensive care units
Authors: Sungyang Jo
Jun Young Chang
Suyeon Jeong
Soo Jeong
Sang-Beom Jeon
Publication date: 01-10-2020
Publisher: Springer Berlin Heidelberg
Keywords: Stroke
Care
ECMO
ECMO
Published in: Journal of Neurology / Issue 10/2020
Print ISSN: 0340-5354
Electronic ISSN: 1432-1459
DOI: https://doi.org/10.1007/s00415-020-09955-5

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Newly developed stroke in patients admitted to non-neurological intensive care units

Abstract

Background

Objective

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Background

Objective

Methods

Results

Conclusions

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