Evaluation of Risk Factors for Invasive Mechanical Ventilation Requirement in Posterior Circulation Stroke

Öz

Ischaemic stroke is recognised as one of the common causes of disability and death today, and it is a primary reason for admission to intensive care units. Posterior circulation strokes account for 20-25% of ischaemic strokes. Respiratory failure is among the leading causes of mortality. Identifying risk factors may aid in taking preventive measures. This study aims to identify the risk factors associated with invasive mechanical ventilation in patients with posterior circulation stroke. This study included patients diagnosed with posterior circulation stroke by the Neurology Clinic at our tertiary centre between 01.01.2019 and 01.01.2021. It was designed to compare patients who required invasive mechanical ventilation with those who did not, and to identify associated risk factors. Independent risk factors for requiring invasive mechanical ventilation in patients with posterior circulation infarcts were found to be stroke-related pneumonia, basilar artery occlusion, and ischaemic stroke due to large artery disease. SOFA and APACHE II scores, along with 28-day mortality rates, were assessed in patients requiring invasive mechanical ventilation. 28-day mortality occurred in 6 patients. The mean SOFA score was 4.72 ± 2.72, and the mean APACHE II score was 19.88 ± 5.34. In this study, the need for invasive mechanical ventilation in posterior circulation strokes was associated with basilar artery occlusion, stroke aetiology being large artery atherosclerosis, presence of stroke-related pneumonia. The main limitation of this study is its retrospective design, and as it was conducted at a single centre, it may not reflect the wider population. Multicentre and prospective studies are necessary to address this issue.

Anahtar Kelimeler

• Posterior circulation stroke
• Respiratory failure
• Mechanical ventilation

Posterior Dolaşım İnfezyonunda İnvaziv Mekanik Ventilasyon Gereksiniminin Risk Faktörlerinin Değerlendirilmesi

Öz

İskemik inme günümüzde yaygın sakatlık ve ölüm nedenlerinden biri olarak kabul edilmekte ve yoğun bakım ünitelerine yatışın birincil nedenidir. Posterior sirkülasyon inmesi, iskemik inmelerin %20-25'ini oluşturur. Solunum yetmezliği önde gelen mortalite nedenleri arasındadır. Risk faktörlerinin belirlenmesi koruyucu önlemlerin alınmasına yardımcı olabilir. Bu çalışma, posterior sirkülasyon inmesinde invaziv mekanik ventilasyon için risk faktörlerini belirlemeyi amaçlamaktadır. Bu çalışmaya, 01.01.2019-01.01.2021 tarihleri arasında üçüncü basamak merkezimiz Nöroloji Kliniği tarafından posterior sirkülasyon inmesi tanısı konulan hastalar dahil edilmiştir. İnvaziv mekanik ventilasyon gerektiren ve gerektirmeyen hastaları karşılaştırmak ve ilişkili risk faktörlerini belirlemek amacıyla tasarlanmıştır. Posterior sirkülasyon infarktüsü olan hastalarda invaziv mekanik ventilasyon gereksinimi için bağımsız risk faktörlerinin inme ilişkili pnömoni, baziler arter tıkanıklığı ve büyük arter hastalığına bağlı iskemik inme olduğu bulunmuştur. İnvaziv mekanik ventilasyon gerektiren hastalarda SOFA ve APACHE II skorları ile 28 günlük mortalite oranları değerlendirilmiştir. 28 günlük mortalite 6 hastada görüldü. Ortalama SOFA skoru 4,72 ± 2,72, ortalama APACHE II skoru ise 19,88 ± 5,34 olarak bulundu. Bu çalışmada, posterior sirkülasyon inmelerinde invaziv mekanik ventilasyon ihtiyacı, inme etyolojisi büyük arter aterosklerozu olan baziler arter oklüzyonu ve inme ilişkili pnömoni varlığı ile ilişkilendirildi. Bu çalışmanın temel sınırlaması retrospektif tasarımıdır ve tek bir merkezde yürütüldüğü için daha geniş popülasyonu yansıtmayabilir. Bu konuyu ele almak için çok merkezli ve prospektif çalışmalara ihtiyaç vardır.

Anahtar Kelimeler

• posterior sirkülasyon inmesi
• solunum yetmezliği
• mekanik ventilasyon

Kaynakça

1. 1. Krishnamurthi RV, Feigin VL, Forouzanfar MH et al. Global and regional burden of first-ever ischaemic and haemorrhagic stroke during 1990–2010: findings from the Global Burden of Disease Study 2010. Lancet Globl Health. 2013;1:259–81.
2. 2. Backhaus R, Aigner F, Schlachetzki F et al. Inventory of a neurological intensive care unit: who is treated and how long? Neurol Res Int. 2015;2015:696038.
3. 3. Bösel J. Use and timing of tracheostomy after severe stroke. Stroke. 2017;48:2638–43
4. 4. Westendorp WF, Nederkoorn PJ, Vermeij JD, Dijkgraaf MG, van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMC Neurol. 2011;11:110.
5. 5. Finlayson O, Kapral M, Hall R, Asllani E, Selchen D, Saposnik G. Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Stroke. 2011;42(12):3374–81.
6. 6. Westendorp WF, Nederkoorn PJ, Vermeij JD, Dijkgraaf MG, van de Beek D. Post-stroke infection: a systematic review and meta-analysis. BMC Neurol. 2011;11:110.
7. 7. Merwick A, Werring D. Posterior circulation ischaemic stroke. Bmj. 2014;348:3175
8. 8. Mattle HP, Arnold M, Lindsberg PJ. Basilar artery occlusion. Lancet Neurol. 2011;10:1002–1014.

9. 9. Flossmann E, Rothwell PM. Prognosis of vertebrobasilar transient ischaemic attack and minor stroke. Brain. Sep 2003;126:1940- 1954
10. 10. Dinç Y, Oğuz Akarsu E, Hakyemez B, Bakar M. Evaluation of risk factors associated with stroke recurrence in patients with minor ischemic stroke. Turk J Neurol 2022;28:14-18.
11. 11. Kumral E, Topcuoglu MA, Onal MZ. Anterior circulation syndromes. Handb Clin Neurol 2008;93:485–536.
12. 12. Easton DJ, Fauci AS, Isselbacher KJ et al. Cerebrovascular disease. Anonymous Harrison's Principle of Internal Medicine. New York, NY: McGraw Hill; 1998: 2325–48.
13. 13. Smith CJ, Kishore AK, Vail A, Chamorro Á, Garau J, Hopkins SJ, et al. Diagnosis of stroke-associated pneumonia: recommendations from the PISCES group. Stroke. 2015;46(8):2335–40.
14. 14. Knaus WA, Draper EA, Wagner DP, Zimmerman J. "APACHE II: a severity of disease classification ;system". Critical Care Medicine. 1985;13 (10): 818–29.
15. 15. Singer M, Deutschman CS, Seymour CW et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-10.
16. 16. Lahiri S, Mayer SA, Fink ME, et al. Mechanical ventilation for acute stroke: a multi-state population-based study. Neurocrit Care. 2015;23:28–32.
17. 17. Robba C, Bonatti G, Battaglini D et al. Mechanical ventilation in patients with acute ischaemic stroke: from pathophysiology to clinical practice. Crit Care. 2019;23(1):388.
18. 18. Tsai A S, B erry K , B eneyto M M et a l. A yearlong immune profile of the systemic response in acute stroke survivors. Brain. 2019;142:978–91.
19. 19. Chamorro Á, Meisel A, Planas AM et al. Stroke-induced immunodeficiency promotes spontaneous bacterial infections and is mediated by sympathetic activation reversal by poststroke T helper cell type 1–like immunostimulation. J Exp Med. 2003;198:725–36.
20. 20. Hoffmann S, Harms H, Ulm L et al. Stroke-induced immunodepression and dysphagia independently predict strokeassociated pneumonia– the PREDICT study. J Cereb Blood Flow Metab. 2017;37:3671–82.
21. 21. Zapata-Arriaza E, Moniche F, Blanca P-G, et al. External validation of the ISAN, A2DS2, and AIS-APS scores for predicting stroke-associated pneumonia. J Stroke Cerebrovasc Dis. 2018;27:673–6.
22. 22. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care–associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control. 2008;36:309–32.
23. 23. Sellars C, Bowie L, Bagg J et al. Risk factors for chest infection in acute stroke: a prospective cohort study. Stroke. 2007;38:2284–2291.
24. 24. Finlayson O, Kapral M, Hall R et al. Stroke Outcome Research Canada (SORCan) Working Group Risk factors, inpatient care, and outcomes of pneumonia after ischemic stroke. Neurology. 2011;77:1338–1345.
25. 25. Matz K, Seyfang L, Dachenhausen A et al. Post-stroke pneumonia at the stroke unit - a registry based analysis of contributing and protective factors. BMC Neurol. 2016;16:107.
26. 26. Lindsberg PJ, Mattle HP. Therapy of basilar artery occlusion: a systematic analysis comparing intra-arterial and intravenous thrombolysis. Stroke. 2006;37(3):922–928.
27. 27. Schonewille WJ, Algra A, Serena J, Molina CA, Kappelle LJ. Outcome in patients with basilar artery occlusion treated conventionally. J Neurol Neurosurg Psychiatry. 2005;76(9):1238–1241.
28. 28. Labauge R, Pages M, Marty-Double C et al. Occlusion of the basilar artery. A review with 17 personal cases (author’s transl). Rev Neurol. 1981;137(10):545–571
29. 29. Demel SL, Broderick JP. Basilar Occlusion Syndromes: An Update. Neurohospitalist. 2015;5(3):142-50.
30. 30. Zhao Y, Han Y, Sun W, Zhang Y. Clinical Symptoms, Etiology and Prognosis of Acute Bilateral Posterior Circulation Cerebral Infarction. Int J Gen Med. 2022;15:2787-2793.