Optimizing Intensive Care in Stroke: A European Perspective

The concept of critical care in stroke is a controversial issue. The question of whether full-scale critical care management of stroke improves patient outcome is still open and probably depends on the definition adopted for critical care. At a second meeting of the European Ad Hoc Consensus Group, the following recommendations for optimal critical care management of stroke patients were made. Emergency Stroke Care: Public and professional education programmes and an active policy should be implemented to reduce the time from stroke symptom onset to initiation of therapy, in order to optimize care for all patients and allow selection of a maximum number of patients eligible for specific acute therapy. The prehospital care services should be made full partners in acute stroke care. As in any other medical emergency, urgent evaluation is paramount; evaluation, by the family physician could result in unnecessary delays. It is essential that a stroke patient be urgently referred by theflrst examining physician to the hospital best equipped to provide the most appropriate acute stroke care. Certain subgroups of patients, including those with large hemispheric infarctions, basilar or vertebral artery occlusion, coma, lower cranial nerve palsy, or systemic complications, e.g. aspiration or concomitant myocardial infarction, may benefit from intensive care if they are identified rapidly. Multi-hospital networks following standard protocols may enlarge the catchment area for stroke units and ensure consistency and continuity of stroke care. Rapid response systems should be developed in individual hospitals to shorten in-hospital treatment delays. Diagnostic delays should be avoided by ensuring that the necessary personnel and equipment are available at all times. A neurologist in attendance or on call should be an integral member of any emergency department that admits acute stroke patients. Intensive Stroke Care: Organized stroke care can reduce mortality and improve functional outcome in acute stroke patients. New techniques for treating stroke subtypes with a poor prognosis require intensive care unit (ICU) facilities and can reduce mortality. The essential elements of stroke intensive care consist of 24-hour availability of third- or fourth-generation computed tomography scanning, Doppler ultrasonography, a neurologist, a neurosurgeon, a neuroradiologist, monitoring (including invasive monitoring) and laboratory services, and optional ventilation capacity. A written protocol, supported by explicit checklists, is necessary to ensure that patient care is standardized. The use of such a protocol can significantly improve outcome and reduce the incidence of complications, the length of hospital stay, and costs. The issues that must be addressed in a protocol for acute stroke care include support of vital functions, detailed diagnostic studies, prevention of deterioration and complications, use of specific acute therapies for appropriate patients, risk factor correction, early and late rehabilitation, and secondary prevention. Specific Problems of Stroke Intensive Care: All patients with moderate to severe acute stroke should be monitored carefully with respect to general and cerebral functions. ECG, oxygen saturation, blood pressure and temperature should ideally be monitored continuously during the first 24 h. Other functions, including blood glucose levels, should be monitored intermittently but frequently. Stroke patients considered at risk of cardiac complications and possible cardiac arrest should be cardiac-monitored preferably for 2–3 days. Routine intracranial pressure (ICP) monitoring should not be performed. Elevation of the head and upper body, combined with osmotherapy and mild hyperventilation if indicated, is recommended as basic treatment for oedema and mass effect in acute ischaemic stroke. Hypertension should not be routinely treated in the acute phase of stroke. Antihypertensive agents may be used with caution, however, in patients with markedly elevated blood pressure at 2 consecutive measurements systolic blood pressure >220 mm Hg, or mean arterial blood pressure (MABP) > 140 mm Hg. As a general guide, MABP should be lowered by decrements no larger than 15 mm Hg. Antihypertensive agents should be chosen appropriately to avoid increases in cerebrovascular blood volume or ICP. An antipyretic and/or an antibiotic should be given immediately for raised temperature, possibly with a cooling blanket, and subcutaneous or intravenous insulin should be used for markedly elevated blood glucose levels. Prophylaxis against deep vein thrombosis and pulmonary embolism is indicated in all acute stroke patients, but anticoagulation should be avoided in those with large intracranial haemorrhage and in selected neurosurgical patients. Physiotherapy as well as speech and occupational therapy should be started as early as possible. The Need for Neurological Intensive Care: Neurological ICUs can improve the survival and outcome of those acute stroke patients who require intensive care. Aggressive approaches to acute stroke therapy, e.g. hypervolaemic-hypertensive therapy, ventricular drainage, decompressive surgery, or experimental use of thrombolytic agents, require management in a specialized neurological ICU. About 10% of hospitalized acute stroke patients require ICU care, which is best provided by staff with specialized training in neurological care. The minimum requirements for optimal neurological intensive care are a 24-hour neurologist or neurointensivist shift service, 1 nurse per patient in attendance at all times, and facilities for advanced haemodynamic, neurological and ICP monitoring.