Fever Prevention in Acute Vascular Brain Injury—Reply

In Reply We appreciate Dr Okazaki’s comments regarding the INTREPID study and the interplay with ICU length of stay. Concerning the severity of primary brain injury and its correlation with ICU length of stay, several principles are important to consider. We enrolled a heterogeneous population, including ischemic stroke, ICH, and SAH, each with relatively predictable ICU courses. For patients with ischemic stroke, the risk of swelling after stroke typically peaks around 3 to 5 days. For patients with ICH, while the swelling risk period (not the hematoma expansion period) is more unpredictable and varies among individual patients, it is generally longer than for ischemic stroke. Regarding patients with SAH, although they require extended monitoring for delayed cerebral ischemia, they may have periods of relative stability. Contrary to Okazaki’s suggestion that enrolled patients were of “lower severity,” the mean National Institutes of Health Stroke Scale score was 17.7 in the fever prevention group and 17.0 in the standard care group. The mean Glasgow Coma Scale score was 10.8 in both groups, and most enrolled patients with ICH and SAH were of higher grade based on the ICH and World Federation of Neurological Surgeons scores, respectively. Furthermore, we have not yet analyzed which patients were more or less likely to experience fever, so the effect of severity of injury is unknown at this time.