Management of acute ischemic stroke

Prior to 1995 no proven therapy existed for acute ischemic stroke. In 1996 the U.S. Food and Drug Administration approved the use of intravenous rt-PA in acute stroke based largely on the results of a two-part trial sponsored by the National Institutes of Health and National Institute of Neurological Disorders and Stroke (NIH/NINDS). Five years following approval, however, thrombolytic treatment remains underutilized, occurring in only 1 to 2% of all stroke patients. The medical community is now being called upon to organize systems capable of delivering acute stroke care in a time-urgent manner not previously contemplated. Critical care specialists may be called upon to treat stroke occurring in hospitalized patients or to continue care initiated in the emergency department. This article briefly reviews the pathogenesis of cellular injury in stroke and its initial evaluation and care and then focuses on the data involving thrombolytic reperfusion. Special attention is given to postthrombolytic critical care issues as these represent an important determinant in patient outcome. Secondary stroke prevention strategies and complication management are discussed along with general intensive care issues for the stroke patient.     

Management of acute ischemic stroke.

Management of an acute ischemic stroke is multifaceted. Treatment in a specialized stroke unit reduces mortality and morbidity. Components of care include interventions to control or prevent medical or neurologic complications, rehabilitation, and initiations of therapies to forestall recurrent stroke. The key to modern treatment is the emergent administration of tissue plasminogen activator (rtPA). Thrombocyte treatment improves outcome when it is given within 3 hours of onset of stroke to carefully selected patients.     

急性缺血性卒中患者的血压管理

急性缺血性卒中患者在发病最初24 h内一般会出现血压增高,且血压水平与患者预后相关.在缺血性卒中急性期的血压管理中,无论是试图升压或是降压治疗都存在争议.文章综述了缺血性卒中急性期血压变化以及血压管理与卒中预后的关系.     

Management of hypertension in the setting of acute ischemic stroke

The optimal management of blood pressure in the first 24 hours of ischemic stroke remains a controversial topic. Most patients are hypertensive at presentation and subsequently experience a spontaneous decline in blood pressure. Decreasing penumbral blood flow and exacerbating vasogenic edema are significant concerns in whether to treat blood pressure elevations. Although an initially elevated blood pressure has been associated with poor outcome, attempts to acutely lower blood pressure are also associated with worsened outcomes. Thus, the current approach in acute ischemic stroke is permissive hypertension, in which antihypertensive treatment is warranted in patients with systolic blood pressure greater than 220 mm Hg, receiving thrombolytic therapy, or with concomitant medical issues. The use of predictable and titratable medications that judiciously reduce (∼ 10% to 15%) the initial presenting mean arterial pressure is recommended in these situations. Future study must define optimal blood pressure goals, likely on an individual basis.     

Treatment of acute ischemic stroke

Acute ischemic stroke is the third leading cause of death in the United States and the leading cause of adult disability. The direct and indirect costs of stroke care exceed $51 billion annually. In 1996, the US Food and Drug Administration approved the first treatment for acute ischemic stroke, intravenous tissue plasminogen activator. Later that year, the National Institute of Neurologic Disorders and Stroke (a branch of the National Institutes of Health) convened a consensus conference on the Rapid Identification and Treatment of Acute Ischemic Stroke, setting goals for stroke care in the United States. Since then, it has become imperative that emergency physicians understand the pathophysiology of stroke, the basis and rationale for treatment, and the therapeutic approaches. This article reviews the state of the art of acute stroke treatment, its foundation, as well as its future.     

急性缺血性脑卒中的TOAST亚型分析

目的 依据TOAST方法对缺血性卒中人群进行亚型分析,总结缺血性卒中发病的病因学特征。方法 2002年7月至2003年2月因首发缺血性卒中在我科住院治疗患者300例,经磁共振成像、磁共振血管造影、数字血管造影等影像学检查及其他病因学检查,依据TOAST分型标准确定每个患者所属亚型。结果 本组患者TOAST亚型的构成比例为：心源性脑栓塞12．3％,大动脉粥样硬化性卒中40．0％,小动脉卒中31．3％,其他原因引发的缺血性卒中5．0％,原因不明的缺血性卒中11．4％。结论本组患者在不同性别之间,TOAST亚型构成比的差异没有统计学意义。本组患者的大动脉粥样硬化性卒中所占比例高于其他4个亚型。     

Antithrombotic treatments in acute ischemic stroke

Ischemic stroke results most commonly from cerebral arterial thrombosis. Antithrombotic agents can reduce the incidence of cerebral embolic events or the extent of tissue injury and neurological outcome. The antiplatelet agents aspirin, ticlopidine, and the combination of dipyridamole and aspirin are associated with a significant reduction in second focal cerebral ischemic events. Oral anticoagulants have a role to reduce the incidence of cardiogenic emboli in patients with mechanical cardiac valves or nonvalvular atrial fibrillation. Both antithrombotics are untested in the acute setting. The recombinant tissue plasminogen activator rt-PA has been shown to significantly increase the number of stroke patients with no or minimal deficit when treated within 3 hours of symptom onset. Additional studies of this and other plasminogen activators by both intravenous and intra-arterial delivery have highlighted limitations to this approach, but also support its role in acute intervention. The risk of intracerebral hemorrhage attends the use of all antithrombotic agents, most notably plasminogen activators. Strategies to decrease this risk are likely to add to beneficial outcome.     

Medical therapy for acute ischemic stroke

Over the past decade, there has been an explosion in data related to the treatment of patients with acute ischemic stroke. Thrombolytic therapy with intravenous tissue plasminogen activator has revolutionized the approach to stroke treatment. Intra-arterial administration of thrombolytic agents is also being investigated and is now being used on a compassionate basis. Medical management can have a large impact on stroke-related outcomes, even in patients who do not receive thrombolytic therapy.     

急性缺血性卒中的血管内低温治疗

大量动物实验和临床研究表明，血管内低温对缺血性卒中具有神经保护作用。文章从作用机制、临床研究、影响治疗结果的因素以及并发症的防治等方面对缺血性卒中的血管内低温治疗进行了综述。     

急性缺血性卒中头位的研究进展

急性缺血性卒中患者采取何种头位,目前仍存在争议。近年来越来越多研究提示改变卒中患者头部位置会影响患者脑血流灌注,进而可能影响患者神经功能恢复。作者总结了近年来发表的急性缺血性卒中头位研究的相关文献,探讨了改变头部位置对脑血流及卒中患者神经功能结局的影响,以提高有关头位对急性脑梗死影响的认识。     

Reperfusion strategies for acute ischemic stroke

Stroke remains a major cause of morbidity and mortality worldwide. Despite preventive measures, effective management strategies are needed to reduce the morbidity and mortality associated with this devastating condition. While the management of hemorrhagic stroke is mostly limited to supportive care, reperfusion strategies in ischemic stroke have been developed and continue to evolve. Conceptually, the pathophysiology of ischemic stroke is similar to that of acute myocardial infarction and the objective of management is similar (ie, to rapidly restore normal flow to reduce permanent damage). It is, therefore, not surprising that the management of acute ischemic stroke includes intravenous (IV) thrombolysis, the only Food and Drug Administration (FDA)-approved strategy at this point. In addition, there are a myriad of emerging endovascular interventional techniques. We review the current literature and discuss some of the technical aspects of endovascular therapy in the setting of acute ischemic stroke.     

急性缺血性卒中溶栓治疗

试验状态 :从 2 0 0 3年 10月开始 ,已经募集 3例患者。试验目的 :比较动脉内rtPA溶栓与静脉rtPA溶栓的疗效。试验设计 :多中心剂量开放随机对照试验 ,采用盲法随访。纳入标准 :大脑中动脉 (MCA)缺血性卒中发病 3h内的患者。排除标准 :卒中发病前已有残疾 ,发病时昏迷 ,神经功能缺损迅速改善 ,发病时出现癫 ,对比增强剂过敏 ,分娩期或哺乳期 ,未经控制的高血压 ,颅内出血 ,溶栓治疗的禁忌证或存在其他有可能增加患者危险的任何情况。患者处理 :患者随机分为静脉溶栓组和动脉内溶栓组 ,静脉溶栓组患者 (rtPA 0 9mg/kg ,最大剂量 90mg)…     

急性缺血性卒中的出血性转化

出血性转化（hemorrhagic transformation,HT）是急性缺血性卒中的重要并发症之一.有关HT的定义、发生率、机制、危险因素及其对急性缺血性卒中预后的影响,目前尚无定论.多数研究显示,少量出血对远期预后无不良影响,但伴有占位效应的脑实质血肿会严重影响近期和远期预后.文章对HT的发生率、发生机制、危险因素和分型以及不同HT亚型对预后的影响进行了综述.     

急性缺血性卒中的脑电图监测

随着影像学技术的不断发展,急性缺血性卒中的早期诊断率不断提高,但有时仍然受病情、环境、设备等条件的限制而无法进行影像学检查或病情追踪,此时采用其他检测技术了解和判断脑内病变严重程度和动态演变过程显得尤为重要.     

急性缺血性卒中动脉再通治疗

动脉再通治疗可快速恢复血流并挽救缺血半暗带组织,已成为急性缺血性卒中最有效的治疗手段.许多新的血管再通方法已应用于临床.文章对该领域的研究进展进行了综述.     

Thrombolytic therapy in acute ischemic stroke

Opinion statement The use of intravenous thrombolytic therapy for the treatment of patients with acute ischemic stroke is now approved in the United States, Canada, Germany, and the European Union. Guidelines published in 1996 from the American Heart Association and American Academy of Neurology committees recommended intravenous administration of recombinant tissue-plasminogen activator (rt-PA) (0.9 mg/kg; maximum of 90 mg) given in a 10% bolus, followed by an infusion lasting 60 minutes, to patients within 3 hours of onset of ischemic stroke. The recommendations stipulate that a computed tomography scan before the infusion should not show major infarction, mass effect, edema, or hemorrhage. Yet, only a small fraction of eligible patients (< 5%) have received rt-PA during the 7 years since its approval in the United States. Although effective, thrombolysis carries an important risk (5% to 10%) of brain hemorrhage and edema that can prove fatal. Many physicians and medical centers are not presently equipped or willing to give thrombolytic drugs for stroke treatment.     

Cerebral autoregulation and acute ischemic stroke

Cerebral autoregulation tightly controls blood flow to the brain by coupling cerebral metabolic demand to cerebral perfusion. In the setting of acute brain injury, such as that caused by ischemic stroke, the continued precise control of cerebral blood flow (CBF) is vital to prevent further injury. Chronic as well as acute elevations in blood pressure are frequently associated with stroke, therefore, understanding the physiological response of the brain to the treatment of hypertension is clinically important. Physiological data obtained in patients with acute ischemic stroke provide no clear evidence that there are alterations in the intrinsic autoregulatory capacity of cerebral blood vessels, except perhaps in infarcted tissue. While it is likely safe to modestly reduce blood pressure by 10-15 mm Hg in most patients with acute ischemic stroke, to date, there are no controlled trial data to indicate that reducing blood pressure is beneficial. There may be subgroups, such as those with persistent large vessel occlusion, large infarcts with edema causing increased intracranial pressure or local mass effect, or chronic hypertension, in which blood pressure reduction may lead to impaired cerebral perfusion in noninfarcted tissue.American Journal of Hypertension 2012; doi:10.1038/ajh.2012.53.