Stroke in the Medical Intensive-Care Unit

Objective To analyze the occurrence and outcome of new-onset stroke in critically ill patients admitted to a medical intensive-care unit. Material and Methods We reviewed the medical records of patients admitted to the medical intensive-care units of two hospitals between 1985 and 1995. In addition, computed tomographic scans or scan reports were assessed. Results We identified 19 patients with a critical medical illness and a new-onset stroke. Of this study group, ischemic stroke developed in 10 patients, 8 of whom were found to have bihemispheric infarction. A single territory infarct (the middle cerebral artery territory) was noted in two patients. The presumed mechanisms for ischemic stroke were disseminated intravascular coagulation (N = 6), cholesterol embolization (N = 1), discontinuation of warfarin therapy before an invasive procedure (N = 1), septic emboli (N = 1), and cardioversion (N = 1). In nine patients, an intracranial hemorrhage developed. Seven patients had a single lobar hematoma, whereas multiple intracerebral hematomas were found in two patients. Disseminated intravascular coagulation and rupture of a mycotic aneurysm in proven infective endocarditis were the most common mechanisms for hemorrhagic stroke. In all patients with an ischemic stroke, sudden hemiparesis rapidly progressed to coma. In patients with an intracranial hematoma and sudden onset of coma, unilateral fixed pupil was the most common initial manifestation. Of the 19 patients, 17 died and 2 remained severely disabled. Conclusion Coma is a common initial manifestation of stroke in patients with a critical medical illness,. and disseminated intravascular coagulation has a major etiologic role. New-onset stroke in the setting of critical medical illness generally is a complication in a terminally ill patient.