Abstract 48: Should Acute Ischemic Stroke Patients with Very High National Institutes of Health Stroke Scale Scores Undergo Pre-procedure Intubation Prior to Endovascular Treatment?

Abstract

Background: Due to higher rates of poor outcomes in endovascular procedures under general anesthesia, it has been proposed that only stroke patients with a very high baseline NIHSS score undergo pre-procedural intubation. Objective: To determine if patients with very high NIHSS score (>20) can undergo endovascular procedure without pre-procedural intubation and how the outcomes compare to procedures were performed after pre-procedural intubation and mechanical ventilation. Methods: All endovascular treated acute ischemic stroke patients identified through a prospective database maintained from two comprehensive stroke centers over a 6-year period. Patients’ risk factors, type of sedation, pre-procedural intubation status, rates of poor outcome at discharge (modified Rankin score [mRS] of >3) and intracerebral hemorrhage (ICH) were obtained and analyzed. The rates of unexpected intubation in patients undergoing procedures without pre-procedural intubation were ascertained. Results: Among the total of 93 patients (mean age 68.5 ± 16.4) with NIHSS score > 20, 61% (57 patients, 49% men) underwent endovascular procedures after pre-procedural intubation. Among the 57 patients who underwent the procedure without pre-procedural intubation, the rates of unexpected intubation secondary to intra-procedural complication was 6 (11%). The mean time interval between CT scan to intiation of procedure was significantly greater among patients who underwent pre-procedural intubation (134±34 versus 170±53 minutes, p<0.001). The risk of post-procedure ICH [OR 0.3, 95% CI 0.1-0.8, p=0.01) and in-hospital mortality [OR 0.1, 95% CI 0.07-0.3, p<0.0001] were significantly lower among patients who did not undergo pre-procedural intubation, after adjusting for potential confounders. The rates of poor outcomes at discharge were significantly lower among those patients who underwent the procedure without pre-procedural intubation [OR 0.3, 95% CI 0.1-0.6, p=0.001]. Conclusions: Despite the risk of unexpected intubation secondary to intra-procedural complication, patients with admission NIHSS score>20 who undergo endovascular treatment without pre-procedural intubation have a decreased risk of poor outcomes, ICH, and death.