A survey of preprocedural intubation practices for endovascular treatment of acute ischemic stroke

Background: In the absence of specific guidelines, there is considerable variance in preprocedural intubation practices for endovascular treatment of acute ischemic stroke. The purpose of this study is to understand and characterize the variance in preprocedural intubation practices and identify the reasons that influence the choice of preprocedural intubation practices among treating physicians.

Methods: We selected 10 random cases from a prospective database of patients undergoing endovascular treatment for acute ischemic stroke and prepared a case summary providing pertinent demographic, clinical, and imaging data. Twenty clinicians independently reviewed the case summaries and responded to whether they would intubate any of the 10 patients and identified the reasons for their choices. Clinicians were also asked to identify their training background (neurology-, neurosurgery-, or radiology-trained endovascular specialist, vascular neurologist or neurointensivist). Reasons for intubation and agreement between clinicians for each case were ascertained.

Results: The decision to intubate the patient was made in 63 of 200 total clinical scenarios. The major reasons identified by the physicians for preprocedural intubation were high National Institute of Health stroke scale scores on admission 26.9% (n = 17), labored breathing or desaturation 23.8% (n = 15), less than optimal respiratory status of patients combined with drowsiness or reduced level of consciousness 14.3% (n = 9), inability to follow command due to aphasia 12.7% (n = 8), seizures 1.6% ( n = 1), and no reason 20.6% (n = 13). Overall agreement between clinicians regarding decision of preprocedural intubation among the 10 case scenarios was 30.1% (standard error [SE] 2.3%). The agreement between neurosurgeons was 37.5% (SE = 31.6), interventional neurologist 19.8% (SE = 4.7), and vascular neurologist/neurointensivist 39.3% (SE = 5.9).

Conclusion: The decision of preprocedural intubation varies widely among clinicians. Because of recent data that suggests that decision of preprocedural intubation may impact on patients' outcomes, better standardization of such practices is required.