Is hyperbaric oxygen therapy (HBOT) recommended for an adult patient with a history of hypertension and diabetes, 6 weeks after a watershed stroke?

Hyperbaric Oxygen Therapy Is Not Recommended 6 Weeks After Watershed Stroke

Hyperbaric oxygen therapy (HBOT) should not be used for your patient 6 weeks after a watershed stroke, as the American Heart Association/American Stroke Association explicitly states that data do not support the routine use of hyperbaric oxygen in the treatment of patients with acute ischemic stroke, and the evidence shows no benefit or potential harm. 1

Why HBOT Is Not Recommended for Routine Ischemic Stroke

Guideline-Based Contraindication

• The American Heart Association/American Stroke Association gives HBOT a Class III: No Benefit recommendation for routine acute ischemic stroke, meaning it should not be used outside of specific exceptions 2, 3
• Studies testing HBOT in stroke have been inconclusive or have shown that the intervention does not improve outcomes 1
• Data from a small trial suggest that hyperbaric oxygen therapy may actually be harmful in stroke patients 1
• A systematic review found no evidence that hyperbaric oxygen improved outcomes after stroke or brain injury 1

The Critical Exception: Air Embolism Only

• HBOT is only recommended for ischemic neurological symptoms secondary to air embolism or caisson disease—not for atherosclerotic or watershed strokes 1, 4
• The 2018 American Heart Association/American Stroke Association guidelines explicitly state that hyperbaric oxygen is not recommended for patients with acute ischemic stroke except when caused by air embolization 4
• Your patient has a watershed stroke from hypertension and diabetes (atherosclerotic disease), not air embolism, making HBOT inappropriate 4

Evidence Quality and Timing Considerations

Why the Evidence Is Definitive Against HBOT

• The most recent high-quality randomized trial (2024) in chronic stroke survivors (6-36 months post-stroke) showed the sham control group performed better than the HBOT group, with a difference of 5.5 points on the Stroke Impact Scale-16 favoring sham treatment (p = 0.01) 5
• This 2024 study specifically excluded a clinically important benefit of HBOT on functional outcomes in the chronic phase of stroke 5
• Multiple systematic reviews consistently show insufficient evidence or no benefit for HBOT in stroke patients 6, 7

The 6-Week Timeline Makes No Difference

• At 6 weeks post-stroke, your patient is in the subacute-to-chronic phase where the theoretical rationale for HBOT (acute tissue oxygenation) is even less applicable 6
• The lack of uniform criteria for HBOT dosage and session duration in different stroke types further undermines its use 8
• Studies have failed to demonstrate benefit in acute, subacute, or chronic stroke phases 6, 7

Common Pitfalls to Avoid

Do Not Confuse HBOT Indications

• Carbon monoxide poisoning: HBOT is strongly recommended and reduces cognitive sequelae by approximately 50% at 6 weeks, 6 months, and 12 months 1
• Air embolism stroke: HBOT is standard treatment and should be initiated immediately 4
• Routine ischemic stroke (including watershed): HBOT is not recommended and may be harmful 1, 5

Patient Comorbidities Do Not Change the Recommendation

• The presence of hypertension and diabetes does not create an indication for HBOT in watershed stroke 1
• These risk factors indicate atherosclerotic disease, which is the standard contraindication for HBOT use in stroke 4

What Should Be Done Instead

Focus on evidence-based secondary stroke prevention for this patient with hypertension and diabetes:

• Optimize blood pressure control to prevent recurrent watershed infarcts 1
• Ensure adequate glycemic control 1
• Implement standard stroke rehabilitation protocols 1
• Address vascular risk factors through medical management 1