Ann K. Helms, Harry T. Whelan and Michel T.

Torbey
Hyperbaric Oxygen Therapy of Acute Ischemic Stroke
Print ISSN: 0039-2499. Online ISSN: 1524-4628
Copyright 2007 American Heart Association, Inc. All rights reserved.
is published by the American Heart Association, 7272 Greenville Avenue, Dallas, TX 75231 Stroke
doi: 10.1161/01.STR.0000259832.57823.83
2007;38:1137; originally published online February 22, 2007; Stroke.
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Hyperbaric Oxygen Therapy of Acute
Ischemic Stroke
To the Editor:
We read with interest the review article by Hankey et al.
1
In an
attempt to assess the treatment of acute stroke with hyperbaric
oxygen (HBO) the authors performed a review of 3 trials.
Although we agree with the statement that there is no level I data
to support the use of HBO in the treatment of acute ischemic
stroke, we would like to emphasize that the trials evaluated by
the authors were not adequate to support their conclusion.
First, none of these studies actually enrolled patients during
what most neurologists would accept as the acute period of
ischemic stroke. Two of the trials looked at patients presenting
up to 24 hours after symptom onset, and the third allowed
enrollment up to 2 weeks after stroke onset. Multiple trials with
acute stroke therapies have clearly shown that the benefit to a
penumbra is limited after the first few hours of ischemia.
Numerous animal studies investigating HBO therapy of acute
cerebral ischemia have also shown that the benefit of HBO is
limited to the first several hours after the onset of ischemia.
2
Secondly, the doses and controls were also not appropriate for
the evaluation of HBO treatment of acute ischemic stroke. The
authors state, HBOT is the therapeutic administration of 100%
oxygen at pressures 1 atmosphere and treatments involve
pressurization to between 152 and 304 kPa (1.5 to 3.0 ATA).
This definition allows for doses much lower than the standard
protocol for all approved indications of HBO in human clinical
use which is 2.0 to 2.4 ATA.
3
Indeed, numerous animal studies
have suggested that if HBO is to be effective in the treatment of
ischemic stroke, it must be applied at doses of 2 to 3 ATA and
administered in the first several hours of ischemia. In 2 of the
reported trials the dose used was 1.5 ATA.
4,5
The authors
misreported the study design of the Nighoghossian trial in the
original Cochrane article,
6
stating that 2.5 ATA of oxygen was
given with 2.5 ATA of air as a control when the trial actually
used 1.5 ATA of oxygen and air at a slight pressure increase as
a control. Such a significant error calls the entire report into
question. Also, the control group in Anderson et al actually
received hyperbaric air as opposed to oxygen, which has been
shown in animal studies to be of intermediate benefit between
hyperbaric oxygen and no treatment. Thus, these 3 studies have
not assessed whether hyperbaric oxygen therapy is effective in
acute ischemic stroke.
The strength of any metaanalysis or review article depends on
the number and quality of clinical trials or articles reviewed. In
this particular article the authors reviewed 3 articles and made a
statement that there is no evidence at this stage to support HBO
in acute stroke. At this stage of the evidence we feel it is too early
to make any conclusions regarding HBO. In fact, there have been
no randomized controlled studies which have appropriately
evaluated HBO for acute ischemic stroke, and thus no statement
should be made about this as-yet untested modality.
Disclosures
None.
Ann K. Helms, MD, MS
Harry T. Whelan, MD
Michel T. Torbey, MD, MPH
Medical College of Wisconsin
Milwaukee, Wis
1. Hankey GJ, Bennett MH, Wasiak J, French C, Kranke P, Schnabel A.
Hyperbaric oxygen therapy for acute ischemic stroke. Stroke. 2006;37:
19531954.
2. Helms AK, Torbey MT, Whelan HT. Hyperbaric oxygen therapy of
cerebral ischemia. Cerebrovasc Dis. 2005;20:417426.
3. Hyperbaric Medicine Practice. Kindwall EP, Whelan HT, eds. Flagstaff,
Arizona:Best Publishing; 1999.
4. Anderson DC, Bottini AG, Jagiella WM, Westphal B, Ford S, Rockswold
GL, Loewenson RB. A pilot study of hyperbaric oxygen in the treatment
of human stroke. Stroke. 1991;22:11371142.
5. Nighoghossian N, Trouillas P, Adeleine P, Salford F. Hyperbaric oxygen
in the treatment of acute ischemic stroke: a double-blind pilot study.
Stroke. 1995;26:13691372.
6. Bennett MH, Wasiak J, Schnabel A, Kranke P, French C. Hyperbaric
oxygen therapy for acute ischemic stroke. The Cochrane Database of
Systematic Reviews. 2005, Issue 3. Art. No.: CD004954.3.
(Stroke. 2007;38:1137.)
2007 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000259832.57823.83
1137
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