Association of Acute Alteration of Consciousness in Patients With Acute Ischemic Stroke With Outcomes and Early Withdrawal of Care

Abstract

Background and objectives: Early consciousness disorder (ECD) after acute ischemic stroke (AIS) is understudied. ECD may influence outcomes and the decision to withhold or withdraw life-sustaining treatment.

Methods: We studied patients with AIS from 2010 to 2019 across 122 hospitals participating in the Florida Stroke Registry. We studied the effect of ECD on in-hospital mortality, withholding or withdrawal of life-sustaining treatment (WLST), ambulation status on discharge, hospital length of stay, and discharge disposition.

Results: Of 238,989 patients with AIS, 32,861 (14%) had ECD at stroke presentation. Overall, average age was 72 years (Q1 61, Q3 82), 49% were women, 63% were White, 18% were Black, and 14% were Hispanic. Compared to patients without ECD, patients with ECD were older (77 vs 72 years), were more often female (54% vs 48%), had more comorbidities, had greater stroke severity as assessed by the National Institutes of Health Stroke Scale (score ≥5 49% vs 27%), had higher WLST rates (21% vs 6%), and had greater in-hospital mortality (9% vs 3%). Using adjusted models accounting for basic characteristics, patients with ECD had greater in-hospital mortality (odds ratio [OR] 2.23, 95% CI 1.98-2.51), had longer hospitalization (OR 1.37, 95% CI 1.33-1.44), were less likely to be discharged home or to rehabilitation (OR 0.54, 95% CI 0.52-0.57), and were less likely to ambulate independently (OR 0.61, 95% CI 0.57-0.64). WLST significantly mediated the effect of ECD on mortality (mediation effect 265; 95% CI 217-314). In temporal trend analysis, we found a significant decrease in early WLST (<2 days) (R² 0.7, p = 0.002) and an increase in late WLST (≥2 days) (R² 0.7, p = 0.004).

Discussion: In this large prospective multicenter stroke registry, patients with AIS presenting with ECD had greater mortality and worse discharge outcomes. Mortality was largely influenced by the WLST decision.

Figure. Temporal Trends From 2010 to 2019 for In-Hospital Mortality and WLST Among Patients With AIS With and Without ECD

Bar graph and lines show trends of mortality and withholding or withdrawal of life-sustaining treatment (WLST) by level of consciousness on presentation (early consciousness disorder [ECD]) in patients with acute ischemic stroke (AIS) between 2010 and 2019 using the Florida Stroke Registry. The orange line shows actual trends of total WLST and the dotted orange line presents the predicted values using the regression trend analysis. The red line shows early (day 0 and 1) trends of WLST and the dotted red line presents the predicted values. The green line shows late (day 2 and after) WLST trends and the dotted green line show the predicted values.