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Acute ischaemic stroke: challenges for the intensivist

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Abstract

Purpose

To provide an update about the rapidly developing changes in the critical care management of acute ischaemic stroke patients.

Methods

A narrative review was conducted in five general areas of acute ischaemic stroke management: reperfusion strategies, anesthesia for endovascular thrombectomy, intensive care unit management, intracranial complications, and ethical considerations.

Results

The introduction of effective reperfusion strategies, including IV thrombolysis and endovascular thrombectomy, has revolutionized the management of acute ischaemic stroke and transformed outcomes for patients. Acute therapeutic efforts are targeted to restoring blood flow to the ischaemic penumbra before irreversible tissue injury has occurred. To optimize patient outcomes, secondary insults, such as hypotension, hyperthermia, or hyperglycaemia, that can extend the penumbral area must also be prevented or corrected. The ICU management of acute ischaemic stroke patients, therefore, focuses on the optimization of systemic physiological homeostasis, management of intracranial complications, and neurological and haemodynamic monitoring after reperfusion therapies. Meticulous blood pressure management is of central importance in improving outcomes, particularly in patients that have undergone reperfusion therapies.

Conclusions

While consensus guidelines are available to guide clinical decision making after acute ischaemic stroke, there is limited high-quality evidence for many of the recommended interventions. However, a bundle of medical, endovascular, and surgical strategies, when applied in a timely and consistent manner, can improve long-term stroke outcomes.

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Author information

Authors and Affiliations

  1. Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK

    M. Smith & U. Reddy

  2. Department of Medical Physics and Biomedical Engineering, University College London, London, UK

    M. Smith

  3. Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa, Italy

    C. Robba

  4. Division of Neuroanesthesiology and Perioperative Neurosciences, Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA

    D. Sharma

  5. School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy

    G. Citerio

  6. Neurointensive Care Unit, San Gerardo Hospital, ASST-Monza, Monza, MB, Italy

    G. Citerio

Authors
  1. M. Smith
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  2. U. Reddy
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  3. C. Robba
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  4. D. Sharma
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  5. G. Citerio
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Corresponding author

Correspondence to M. Smith.

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Conflicts of interest

MS is Editor-in-Chief of the Journal of Neurosurgical Anesthesiology. CR is a junior Editor of Intensive Care Medicine. GC is Editor-in-Chief of Intensive Care Medicine. The authors have no other conflicts to declare.

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Smith, M., Reddy, U., Robba, C. et al. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med 45, 1177–1189 (2019). https://doi.org/10.1007/s00134-019-05705-y

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