Acute Treatment of Ischemic Stroke

Although treatment of risk factors and secondary prevention are helpful with regard to preventing first or new stroke, they continue to happen. It has been shown in several settings that acute treatment of stroke, especially in stroke units, definitely improves outcome and lowers mortality after stroke [Stroke Units Trialists’ Collaboration, 1997]. There are four main areas in the treatment of acute stroke. The first one is the treatment of general physiological conditions that need to become optimised in the setting of an acute stroke. This is usually referred to as ‘general therapy’. The second is the specific therapy that is directed against different aspects of stroke pathogenesis. Since stroke is mainly caused by acute local or embolic vascular occlusion, one of these aspects is re-canalisation. Another approach aims at the neuronal injury that happens after brain ischaemia, generally referred to as neuroprotection, an area, for which we do not yet have strong evidence that it works. The third main area of stroke treatment is prophylaxis and treatment of complications, which may be either neurological (such as secondary haemorrhage, space-occupying oedema or seizures) or medical (such as infections, decubital ulcers or pulmonary embolism). All these aspects of acute stroke treatment will be covered in this article. The fourth area, early rehabilitation, has already been covered in the first article of this series of recommendations.If a patient arrives at the ward, the key questions to be answered are: 1 Is it a stroke? 2 Is there a life-threatening concomitant disease? 3 What kind of stroke is this? 4 Where in the brain is it? 5 What is the aetiology (is it likely to be arteriosclerosis related, cardio-embolic, haemodynamic or are there small vessel lesions? 6 How dangerous is the stroke (are there signs of poor prognosis)?An initial idea about stroke aetiology is derived from the neurovascular examination, which focuses on the neck vessels, the intracranial vessels, and the heart. Stroke severity and prognosis in ischaemic stroke are, in general, correlated with the severity of the neurologic deficit and the presence or absence of very early ischaemic changes on the initial CT scan. Dense hemiplegia, forced eye deviation and decreased level of consciousness predict poor outcome.Patients with an acute stroke cannot be managed in institutions not meeting the basic requirements detailed in the first article of these recommendations. They should be transferred to a qualified hospital immediately after basic assessment and stabilization of vital functions.There is no fixed sequence of how the different methods should be used. Usually, after blood tests have been ordered, the first test will be (cranial) computerized tomography (CT). This test is needed to establish the differential diagnosis between an intracerebral haemorrhage (ICH) and acute ischaemic stroke. In addition, other intracranial pathologies such as an abscess, an apoplectic glioma, encephalitis, sinus venous thrombosis and occasionally unexpected subarachnoid haemorrhage will be identified using CT. However, just the physical presence of a CT scanner is not sufficient. Expertise in the assessment of subtile early infarctions may be essential not only for identification of patients who may be treated with thrombolytics, but also for patients with bad prognosis and risk of secondary haemorrhage and herniation. In some instances, especially if an expert Doppler study can be performed without delay, it can be done prior to CT scan. Magnetic resonance imaging (MRI) has not yet become part of a routine assessment of the acute stroke patient. Modern sequences capable to visualise vessels (MR angiography), to estimate brain perfusion (perfusion-weighted MR) or to assess early cytotoxic oedema (diffusion-weighted imaging) may in the future play an important role in early stroke management.In all stroke patients, neurological status and vital functions (blood pressure, pulse rate, temperature) should be continuously or discontinuously monitored. Neurological status is best monitored using validated scales/subscales. In selected cases with pre-existing cardiac disease, history of arrhythmias and unstable blood pressure, on-line ECG monitoring is desirable. The electrodes for cardiac monitoring can also be used for respiratory monitoring. Respiratory action is checked clinically if there is no continuous monitoring. Blood pressure monitoring can be performed discontinuously using repetitive automatic inflatable sphygmomanometry or with a mobile 24-hour blood pressure monitoring device. Most of the times, conventional blood pressure monitoring is adequate. Pulse oxymetry is frequently used for continuous monitoring in stroke units. It provides relevant information on the patient’s respiratory status. A central catheter and occasionally central venous pressure monitoring is needed for patients with severe stroke treated in specialised wards. Via a central venous catheter, indirect information on intravascular volume, cardiac function and compliance within the venous system can be gained.In most stroke patients, the acute neurologic symptoms are prominent, but treatment and prognosis are co-determined by the underlying and associated systemic diseases that are almost always present. The early discovery and treatment of systemic problems can help prevent later complications. The term ‘general treatment’ refers to treatment strategies, which are not exclusive to stroke treatment. It rather describes what has to be done for every ill patient in order to provide an optimum physiological basis upon which specific therapeutic treatment strategies can be built [Hacke et al., 1995; Brott et al., 1994]. There is consensus that management of general (internal medical) problems is the basis for stroke treatment [WHO Tasks Force on Stroke and Other Cerebrovascular Disorders, 1989; Brott and Reed, 1989; Adams et al., 1994; The European Ad Hoc Consensus Group, 1996]. General management of stroke patients comprises respiratory and cardiac care, fluid and metabolic management, blood pressure control and perhaps treatment of elevated intracranial pressure. In addition, treatment of seizures and prophylactic measures concerning deep venous thrombosis (DVT), pulmonary embolism, aspiration pneumonia, other infections and decubital ulcer are part of the general treatment of the patients [The European Ad Hoc Consensus Group, 1996, 1997, 1998].Most authors agree that adequate treatment and preservation of vital functions constitute the basis of all therapeutic measures in acute stroke, not only in stroke units, but also in normal wards. On the other hand, one has to keep in mind that even the proposed management of hypertension, hyperglycaemia or fever in stroke patients has never been tested prospectively. It makes sense to keep the patient’s general condition in the best physiological shape possible, but in the past, even this has been controversial, as one can see in the changing attitude towards treatment of elevated blood pressure [Einhäupl et al., 1999; Adams et al., 1994; Barsan et al., 1989].Like in the ER, adequate blood oxygenation with normal respiratory function is required for stroke management, although there is no convincing prospective clinical evidence that oxygen supply at low flow rates is useful in human brain infarction. Adequate oxygenation and hyperventilation are without effect on a structurally damaged ischaemic region, but they may be important for the preservation of metabolic turnover in the marginal zone of the insult, the so-called penumbra.A threatened airway may be found in patients with severe pneumonia, heart failure, extensive vertebrobasilar or hemispheric infarction, with large intracranial haemorrhages or with patients with sustained seizure activity following hemispheric stroke. Overt pulmonary dysfunction is occasionally present in the form of slightly exacerbated chronic obstructive airway disease. Some patients develop early AV shunts and require oxygen or even intubation and ventilation. Blood gas analysis (BGA) or an expiratory pCO2 and transcutaneous O2 assessment should be performed early in selected patients with either severe stroke or impaired pulmonary function. Ventilation may be particularly compromised during sleep. Continuous transdermal pulse oxymetry may provide useful information; however, peripheral oxygen saturation of 90% or higher does not necessarily reflect the situation within the brain, particularly within the deep white matter. The oxygenation of the blood is improved by the administration of 2–4 liters O2/min via a nasal tube, and by the use of bronchospasmolytics.If there is no pathological respiratory pattern, and the BGA reveals only moderate hypoxaemia, the administration of oxygen is probably sufficient. In the event of a pathological respiratory pattern, severe hypoxaemia or hypercarbia, and for the unconscious patient at high risk for aspiration, early endotracheal intubation is recommended. In the past, many neurologists did not consider stroke patients candidates for intubation and ventilation, except for those electively intubated for angiography or operation. This attitude is changing. Of course, before intubation is performed, the general prognosis, co-existing life-threatening medical conditions and the presumed will of the patient and his family have to be taken into account. On the other hand, prognosis of stroke patients undergoing intubation is not as bad as reported previously [Grotta et al., 1995] with a 1-year survival rate of about one third of the patients [Steiner et al., 1997]. Prophylactic measures against aspiration have to be taken immediatley. Patients with swallowing disturbances and impaired brain stem reflexes should receive a gastric tube early.Cardiac arrhythmias secondary to stroke are not unusual. Significant alterations in the ST segments and the T waves on the ECG may appear in the acute phase mimicking myocardial ischaemia [Norris, 1983], and cardiac enzymes may be elevated after stroke [Kaste et al., 1978]. Every stroke patient should have an initial ECG. If this is normal, usually no continuous ECG monitoring is required. However, patients with major stroke syndromes and some haemodynamic instability should be continuously monitored and be transmitted to a facility where monitoring can be continued [Furlan, the intravascular be the has the of cardiac without either heart rate or blood pressure. may be particularly useful in patients with or and may be with a low of cardiac can blood flow in cardiac may perfusion in areas which have after acute all cardiac after ischaemia should be as There is a of myocardial infarction, not particularly clinically with ischaemia [Kaste et al., use of is only there are signs of myocardial of normal by using or should be performed in with or cardiac with of a high normal blood pressure and a normal heart rate is the essential basis of stroke The should be at and although not frequently used in a normal ward, will early of a or which have on pressure monitoring and treatment is a In to the that blood pressure should be performed in every acute stroke the treatment of for is patients with acute have elevated blood pressure. may be in an area of that flow in the zone is on the pressure a between blood flow and the metabolic of brain of the is in preventing brain is In normal is at a of in blood pressure be if an adequate perfusion pressure is to be A blood pressure of and blood pressure of is for patients with prior In other is those a high blood pressure is after an ischaemic this does not to high blood pressure or some especially in of and are constitute an for early but even the in blood pressure should not be are only for therapy in the first after may be in the setting of acute myocardial ischaemia of blood pressure is for patients cardiac acute or acute the CT has shown a of stroke, such as subarachnoid haemorrhage or or treatment may also be In ischaemic stroke, therapy in the first may be dangerous in local within the area of infarction. In addition, in stroke patients, the is to the higher of chronic upon a blood pressure in a of used for treatment of in acute stroke are in 1 and high of should be of the risk of and administration are frequently used in although the of are frequently and The is for In the of action is to has been as an et al., In which is in or are frequently recommended. and cardiac are after is used. will become some major which and of blood pressure, and are frequently although are to intracranial pressure stroke patients are is for the first after an ischaemic has A pre-existing metabolic may be in the acute phase of stroke, and treatment may become are not in stroke et al., blood level of or and higher the blood level is no should be to a stroke can an acute ischaemic infarction, and signs are not always those of a On the other hand, should be by of via a central venous neurological outcome after stroke et al., et al., 1996]. is a risk for stroke et al., and many patients develop an after stroke et al., fever Although there are no to it to be to an elevated in stroke such as and the early use of in cases of such as or aspiration are usually recommended. Although there are no prospective one may consider as as it patients should have a fluid and status to and of of the blood In the presence of intracerebral pressure, a slightly fluid is usually recommended. The should be monitored and If is should be to an may to pulmonary oedema and cardiac and is needed for initial fluid management and blood If of need to be with high are or if they are that may the venous of a central venous catheter is recommended. venous the of high and high of that continuous ECG monitoring is are in stroke. In the may to or to of et al., is managed by fluid or should be if is et al., 1 Patients should be treated in a stroke 2 Neurological status and vital functions should be monitored 3 and provide adequate 4 not in the first phase after stroke if there are no high or 5 and and if 6 monitoring and of disturbances is of the concerning general treatment has been in However, the of stroke to some may be caused by to for general which may be used as an indirect of of general treatment therapy with within 3 after stroke to patients with acute ischaemic stroke improves outcome after stroke [The of Neurological and Stroke Stroke Group, This treatment is not yet in it is in There is evidence that may also to 6 after stroke in identified patients [Hacke et al., and The of a to did not on outcome or mortality et al., This therapy is not In there is some about risk which some from is before to with severe stroke stroke or if the CT early changes of a major infarction, such as effect and In where therapy is it should only be if the diagnosis is by a who has in the diagnosis of stroke, and a CT of the brain is by who have in this imaging the use of the risk of major the and of should be with the patient and family before treatment is A of all an in patients without or mortality and to the in acute ischaemic stroke to be within 3 and 6 of stroke. However, the consider the of patients to be that there is evidence on which of stroke particularly or be and not evidence to about the effect of in acute stroke. administration of 3 after stroke should only be in an as has been shown to be associated with an risk of haemorrhage and [The Stroke Group, et al., therapy of of the part of the using has been shown to be associated with outcome in a This treatment angiography and is only in selected et al., The treatment is and in a treatment of acute with or is frequently used in selected but has not been to a [Hacke et al., et al., for 1 with of the as a by an is the treatment within 3 of of ischaemic stroke 2 The from the use of for acute ischaemic stroke 3 after of the symptoms is but present in selected patients 3 is not the of of stroke cannot be this are upon 4 administration of the setting of a clinical is dangerous and not for the management of with ischaemic stroke 5 on the or of other are not to provide a 6 treatment of acute in a using in a improved outcome may be treated with therapy in selected a has been shown to outcome after acute ischaemic stroke if within 3 after stroke and 5 for the Group, a European treatment in a has been 1 in a improves outcome after acute ischaemic stroke of very large that within after stroke to mortality and rate of stroke but Stroke Group, Stroke 1997]. the effect of early is to an effect on the or to prevention of is not yet It may be that the effect of may also the has been used frequently in treatment after acute ischaemic stroke. of the that have been performed in the has the idea that early may outcome after ischaemic stroke or at may the of that used [The et al., 1995; et al., or Stroke Group, to an of treatment there some kind of in outcome or in stroke this almost always by an of complications. In the no have been performed to test the of early with conventional following acute ischaemic stroke, which is used frequently in many In addition, many that is not and never will be a therapy for all stroke However, they that patients (such as patients with stroke associated with for should be et al., a study is not and the for the use of acute after ischaemic stroke are not evidence 3 some as to may be it is to the to the should only be as as it to on the secondary for the treatment with large of and changes in the that lowers the by or in in blood and in large clinical of to a in mortality of with treatment Stroke Group, Stroke Group, The in Stroke Group, has been in small with The clinical of therapy has not been and the of brain oedema has not been a has been shown to outcome after stroke. there is no to patients with after ischaemic 1 There is no for general use of or after ischaemic stroke 2 may be used there are selected such as other cardiac with high risk of or 3 may be after stroke to an even without CT 4 therapy is not for the management of patients with acute ischaemic stroke 5 there is no to patients with of the ischaemic stroke stroke to medical such as pneumonia, infections, or Patients may also from and pulmonary and monitoring of physiological may prevent such complications. This is best done in a stroke with and early may to infections, and decubital of the most important in the early phase after stroke is aspiration for of stroke et al., The of the are caused by aspiration et al., Since aspiration may be by in as many as of patients during the initial after stroke should be the patient has swallowing with small of and on is frequently found in patients with but also in patients with impaired reflexes or with swallowing which are not only found after brain stem stroke. may be helpful in the prevention of aspiration pneumonia, although it does not the Other for to poor and changes of the patient in and pulmonary physical therapy may prevent this of stroke patients have swallowing This can be tested early and with a of or a small A gastric tube should be early if are tube is adequate for but are used early if is is the medical of acute infarction. It is but not in as many as of patients from stroke et al., A catheter or catheter is frequently is in the early phase after stroke. is The of infections are associated with the use of On the other hand, or is not always in the setting of severe stroke and may to decubital infections may in patients who have an catheter and in those who have are to a risk of may the risk of has not been shown to have a is should be However, there is no need for prophylactic of acute pulmonary et al., is of major in the of every patient with stroke. is the of in to of patients following ischaemic infarction, even in patients who have an from the stroke. The risk of and pulmonary can be by early and by the use of or However, this effect to be by an in complications. with every has been for stroke are for patients to as they can the risk of and are signs of pulmonary of Since and will in of those patients with pulmonary embolism, and should be to those of should be performed to signs of therapy and are as an of patients is useful for prevention of decubital The of the patient be patients at particularly high an or system should be used. If the does not to therapy may be for several or secondary may in the acute phase of ischaemic stroke. or by either or or are the of are treated in the acute phase with There is no evidence that prophylactic treatment is and are caused by the stroke, but frequently a of other such as and Adequate treatment of the underlying of or 1 of or in patients after stroke is to the of and pulmonary however, there is a risk of intracranial 2 after stroke should be treated with may be by 3 is helpful to prevent after stroke aspiration pneumonia, and decubital ulcers 4 of to prevent seizures is 5 Prophylactic administration of to patients with stroke who have not seizures is not brain oedema during the first after ischaemic In patients with infarction, brain oedema and elevated may become a major and may to and [Hacke et al., 1996]. patients usually a in consciousness and develop the signs of 2–4 after the of in the of these patients, with a mortality of about with treatment et al., 1995; et al., management of elevated following stroke at an of of and is the first medical treatment to be used if signs of space-occupying oedema In the of in many is It is usually of using 4 is an In is with every should be to the in the and should be as and other are not used for brain oedema treatment after stroke. such as as a can and the of action is the of intracranial blood The effect is only and the management of an acute prior to treatment and monitoring and monitoring of haemodynamic as a blood pressure may Usually, be to this Continuous are of no and may have [Hacke et al., may be used as treatment to this condition cannot be with medical treatment and the patients will and if no et al., or is performed et al., et al., 1995; et al., The may with space-occupying et al., is evidence that is after and injury to the brain et al., et that with brain between and did not The mortality rate in this of patients from the history of the disease. This is small to outcome however, this is and will be tested in a prospective in in several the of is to of the from the the and the to to perfusion pressure and to by preventing of the factors may help to in areas ischaemic preventing brain In large prospective therapy in hemispheric space-occupying lowers mortality from to without the rate of et al., within the first after stroke can mortality even et al., A study has been and is is the treatment of for a space-occupying infarction, although the basis for this is by no in hemispheric are caused by or or by patients with space-occupying infarctions have a mortality of about if treated This high mortality can be to if is performed et al., in space-occupying infarction, the should be performed before signs of are present. The prognosis is very even if they the Most of a of or It should be however, that these are the of small or one of but from a are 1 is for patients condition is secondary to those with syndromes 2 and of large infarctions that the brain stem is 3 and of a large hemispheric can be a may have a neurological deficit that an