Association of liberal versus restrictive oxygen saturation targets with mortality in mechanically ventilated stroke patients: a multicenter retrospective propensity-matched analysis
9 affiliations
- 1International University of the Health Sciences
- 2FAJR Global
- 3Wayne State University School of Medicine
- 4Michigan State University College of Human Medicine
- 5Department of Family and Community Medicine, University of Toronto
- 6Outcomes Research Consortium
- 7Trauma and Acute Care Service, Southern Illinois Healthcare
- 8Southern Illinois University School of Medicine
- 9Brain and Spine Institute, Southern Illinois Healthcare
Abstract
Background: Optimal oxygen saturation targets in mechanically ventilated stroke patients remain uncertain. While restrictive oxygen strategies are increasingly adopted in general critical care, their impact in acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) are unclear. We evaluated the association between restrictive versus liberal oxygen saturation targets during the first 48 h of mechanical ventilation and short-term mortality in stroke patients.
Methods: We conducted a multicenter retrospective cohort study using the TriNetX database (2006–2026). Adult patients (≥18 years) with a stroke diagnosis who required invasive mechanical ventilation and had documented peripheral oxygen saturation (SpO₂) values within the first 48 h of ventilation were included. Patients were stratified according to early oxygen saturation targets: restrictive (SpO₂ 92–96%) versus liberal (SpO₂ ≥ 97%). Propensity score matching (PSM) by demographics, comorbidities, and stroke severity was performed separately within the combined stroke cohort and prespecified AIS and ICH subgroups to balance demographic and clinical covariates. The primary outcome was all-cause mortality at 30 and 90 days. Secondary outcomes included 30-day tracheostomy and ventilator-associated pneumonia. Time-to-event analyses were performed using Kaplan–Meier methods and Cox proportional hazards models. p -value was set at 0.05.
Results: Among 17,207 mechanically ventilated stroke patients, 2,366 received restrictive and 14,841 liberal oxygen saturation targets prior to matching. After PSM, 2,350 patients remained in each group. Restrictive oxygenation during the first 48 h was associated with higher mortality at 1 month (HR 1.13, 95% CI 1.03–1.23; p = 0.008) and 3 months (HR 1.11, 95% CI 1.02–1.20; p = 0.014). In AIS, restrictive oxygenation was similarly associated with increased mortality at 1 month (HR 1.26, 95% CI 1.11–1.43) and 3 months (HR 1.22, 95% CI 1.08–1.37). No statistically significant mortality difference was observed in ICH. Restrictive oxygenation was associated with lower 30-day tracheostomy rates (8.5% vs. 13.1%; RR 0.653, p < 0.001), with no difference in VAP.
Conclusion: Restrictive oxygen saturation targets during the first 48 h of mechanical ventilation may be associated with higher short-term mortality in stroke, driven primarily by the AIS group. These findings suggest that early oxygenation strategy may have subtype-specific implications and warrant prospective evaluation in stroke focused randomized trials.
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BibTeX
@article{ghafarian2026association,
title = {{Association of liberal versus restrictive oxygen saturation targets with mortality in mechanically ventilated stroke patients: a multicenter retrospective propensity-matched analysis}},
author = {Amir Ghafarian and Jawad Saad and Muaaz Wajahath and Mohammad Ghafarian and Wael Saasouh and Khaled Saleh and Mosab Nasser and Abbasali Badami and Awni D. Shahait and Andrea Loggini},
journal = {Frontiers in Neurology},
year = {2026},
month = oct,
doi = {10.3389/fneur.2026.1840183},
url = {https://www.frontiersin.org/articles/10.3389/fneur.2026.1840183/full},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Association of liberal versus restrictive oxygen saturation targets with mortality in mechanically ventilated stroke patients: a multicenter retrospective propensity-matched analysis
AU - Amir Ghafarian
AU - Jawad Saad
AU - Muaaz Wajahath
AU - Mohammad Ghafarian
AU - Wael Saasouh
AU - Khaled Saleh
AU - Mosab Nasser
AU - Abbasali Badami
AU - Awni D. Shahait
AU - Andrea Loggini
PY - 2026
DA - 2026/10/19
JO - Frontiers in Neurology
DO - 10.3389/fneur.2026.1840183
UR - https://www.frontiersin.org/articles/10.3389/fneur.2026.1840183/full
AB - Background: Optimal oxygen saturation targets in mechanically ventilated stroke patients remain uncertain. While restrictive oxygen strategies are increasingly adopted in general critical care, their impact in acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) are unclear. We evaluated the association between restrictive versus liberal oxygen saturation targets during the first 48 h of mechanical ventilation and short-term mortality in stroke patients. Methods: We conducted a multicenter retrospective cohort study using the TriNetX database (2006–2026). Adult patients (≥18 years) with a stroke diagnosis who required invasive mechanical ventilation and had documented peripheral oxygen saturation (SpO₂) values within the first 48 h of ventilation were included. Patients were stratified according to early oxygen saturation targets: restrictive (SpO₂ 92–96%) versus liberal (SpO₂ ≥ 97%). Propensity score matching (PSM) by demographics, comorbidities, and stroke severity was performed separately within the combined stroke cohort and prespecified AIS and ICH subgroups to balance demographic and clinical covariates. The primary outcome was all-cause mortality at 30 and 90 days. Secondary outcomes included 30-day tracheostomy and ventilator-associated pneumonia. Time-to-event analyses were performed using Kaplan–Meier methods and Cox proportional hazards models. p -value was set at 0.05. Results: Among 17,207 mechanically ventilated stroke patients, 2,366 received restrictive and 14,841 liberal oxygen saturation targets prior to matching. After PSM, 2,350 patients remained in each group. Restrictive oxygenation during the first 48 h was associated with higher mortality at 1 month (HR 1.13, 95% CI 1.03–1.23; p = 0.008) and 3 months (HR 1.11, 95% CI 1.02–1.20; p = 0.014). In AIS, restrictive oxygenation was similarly associated with increased mortality at 1 month (HR 1.26, 95% CI 1.11–1.43) and 3 months (HR 1.22, 95% CI 1.08–1.37). No statistically significant mortality difference was observed in ICH. Restrictive oxygenation was associated with lower 30-day tracheostomy rates (8.5% vs. 13.1%; RR 0.653, p < 0.001), with no difference in VAP. Conclusion: Restrictive oxygen saturation targets during the first 48 h of mechanical ventilation may be associated with higher short-term mortality in stroke, driven primarily by the AIS group. These findings suggest that early oxygenation strategy may have subtype-specific implications and warrant prospective evaluation in stroke focused randomized trials.
SN - 1664-2295
ER -